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LACERATIONS 



FEMALE PERINEUM 



VESICO-VAGINAL FISTULA: 



THEIR HISTORY AND TREATMENT, 



BY 

D. HAYES AGNEW, M.D., 

TROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA. 



NUMEROUS ILLUSTRATIONS 



> m- 



PHILADELPHIA: 

LINDSAY AND BLAKISTOE". 
18*13. 




/3 



7 
a 7 



Entered iiccording to Act of Congress, in the year 1873, by 

LINDSAY AND BLAKISTON, 

in the Office of Librarian of Congress. 



PHILADELPHIA: 
COLLIN?, PRINTER, 

705 Jayne Street. 



INTRODUCTION. 



The subjects of the present volume appeared several years 
ago ; the first in the Pennsylvania Hospital Reports, published 
by Messrs. Lindsay & Blakiston, and the second in the pages 
of the Medical and Surgical Reporter, edited by Dr. Butler. 

As applications are constantly received for these papers, 
the writer, has deemed it proper to place them before the 
profession in their present form. 



LACERATION OF THE FEMALE PERINEUM: 

ITS HISTORY AND TREATMENT. 



"When it is considered that the female perineum measures 
in its normal condition from one to one and a half inch, 
and yet, during the final act of parturition is extended to 
four and a half — perhaps five — inches, and of course greatly 
attenuated, it is not surprising that a separation in its con- 
tinuity should frequently occur. 

Such accidents doubtless take place in a large majority of 
cases from ignorance or carelessness on the part of the medi- 
cal attendant, and yet may and do happen in the hands of 
the most competent and expert practitioners. The conse- 
quences which often ensue are so peculiarly distressing and 
mortifying to the female, as to debar her from the compan- 
ionship of friends, render her offensive to herself, and seri- 
ously to undermine her health. In some degrees of this 
injury the patient's situation is infinitely worse than when 
afflicted with a vesico-vaginal fistula ; and like the latter, 
until a comparatively recent period, was deemed beyond the 
compass of surgical resource. It is almost exclusively the 
result of parturition, though occasionally we hear of such 
lacerations from external violence, as falling astride the back 
of a chair, or as in the case related by Prof. H. H. Smith 
(Smith's Surgery, vol. ii., page 555), where the injury was 
produced by the horn of an enraged deer. 

Partial lacerations are by no means uncommon, and even 

extensive ones, I am disposed to believe, exist to a degree 

not generally suspected. Many females, from motives of 

delicacy, timidity, or hopelessness, carefully conceal such, suf- 

2 



10 



LACERATION OF THE FEMALE PERINEUM. 



fering in silence the many evils which they entail. The 
successful management of these, in any degree, constitutes 
one of the most important triumphs of modern Surgery ; 
and if there is any class in this world, more than another, 
placed under unbounded obligations to cherish and respect 
our art, it is the mothers of the land. 

Anatomy of the Female Perineum. 

The subject of this paper cannot be well understood with- 
out some presentation of the anatomical components of the 
female perineum. It extends, in a restricted sense, from the 
commissural connection of the labia majora to the anus. 
The two canals, vagina and rectum, as they approach their 
terminations — vulva and anus — recede from each other, 
leaving a triangular space into which the deep portions of 
the perineum extend. (Fig. 1.) 



Fig. 1, 




1. Vagina; 2. Rectum; 3 Triangular notch or space into which penetrates 
the perineum. 

Just within the posterior commissure of the labia majora, 
is a transverse duplicature called the fourchette. This is al- 
most constantly torn across in the first labor, but is followed 
by no inconvenience whatever. The skin and superficial 
fascia being removed, the muscular apparatus is exposed ; 
consisting of the external sphincter ani. Its origin com- 
mences at the coccyx. At the posterior side of the bowel it 
separates into two elliptical planes which surround the anus, 
unite in front, and become inserted into the perineal centre. 



ANATOMY OF THE FEMALE PERINEUM. 



11 



Below this lies a strong muscular ring, surrounding the 
lower end of the bowel, the sphincter ani interims. At the 
perineal centre commences the sphincter vaginae, continuous 
with the fibres of the sphincter ani, and passing forwards on 
either side of the vagina, is inserted into the cavernous por- 
tions of the clitoris. 

On either side, arising from the ramus of the ischium, are 
the transverse perineal muscles, inserted into the constric- 
tor vaginas. In like manner, on each side, there is a levator 
ani stretching between the pubic bone and the spine of the 
ischium, and inserted into the side of both the vagina and 
rectum. (See Fig. 2.) With a knowledge of these muscles, 

FiQ-. 2. 




1. Sphincter vagina ; 2. Sphincter ani externus ; 3. Internus : 4. Transversus 
perinei; 5. Levator ani et vaginae ; 6. Perineal centre. 

their attachments and direction, it will not be difficult to 
understand the displacement of parts which follows lacera- 
tions, and which we shall have occasion to refer to presently. 
Period of Occurrence.^- As might be expected, these acci- 
dents are largely confined to primiparse. I. Baker Brown, 
whose experience has been very great in this as in many 
other diseases incident to the female sexual system, states 



12 LACERATION OF THE FEMALE PERINEUM. 

that in eighty-six cases operated upon, sixty-four occurred 
in first labors, and in those which have suggested this paper, 
all were in the persons of primiparse, none of whom but two 
at the time of the injury exceeded twenty -five years of age. 

Causes. — These may be arranged under three heads. First, 
such as relates to the mother ; second, to the child ; and third, 
to instruments. Under the first, may be mentioned powerful 
expulsive uterine contractions extruding the foetus before the 
parts are sufficiently extended ; or an unyielding perineum, 
its tissues being rigid ; or where the muscular structure is 
deficient in tone and inadequate to react against the pressure 
of the advancing head ; and again, where the uterine contrac- 
tions are suspended at a period when the perineum is greatly 
stretched, and then, without premonition, recommence with 
unusual power. In such a case laceration occurs in one of 
two modes ; either by the muscles contracting powerfully to 
meet the emergency ; or by their being so enfeebled by pro- 
tracted extension, as to be powerless to resist. 

The form of the perineum itself must not be overlooked. 
There are congenital peculiarities which complicate the me- 
chanism of a labor, resulting from redundancy of tissue asso- 
ciated often with an unusual straight sacrum, in consequence 
of which, the presenting part of the foetus tends to direct 
protrusion, instead of being deflected in the axis of the pelvic 
curve. A very narrow pubic arch may predispose to the 
accident by preventing the usual extension. 

Under the second head are such as relate to the child. Of 
these may be specified unusual size of the head or breadth 
of the shoulders, either from natural or morbid causes, de- 
manding for their passage an extraordinary dilatation of the 
vaginal outlet ; or, unusual position of the foetus. It is a 
question by no means clear, whether the passage of the 
shoulders does not often produce the damage ascribed to the 
head. 

The third cause of lacerations is the use of instruments. 
These come in usually for a very large share of animadver- 
sion, but it is only in unskilful hands they can be said to do 
harm in this way. If a child is dragged through the ma- 



ANATOMY OF THE FEMALE PERINEUM. 13 

ternal passages without regard to- the existence of a pelvic 
curve or the principle of the lever, then, indeed, great dam- 
age may be done ; or if the accoucheur, before he has the 
blades of his instrument adjusted, allows himself to be sur- 
prised by the sudden expulsion of head and instrument 
together, the parts may, indeed, be seriously wounded. One 
of the most fearful perineal lacerations I have witnessed, 
extending some distance up the rectum, was produced in this 
manner. In the hands of an expert, instruments I regard as 
among the most valuable resources of obstetric surgery, pre- 
venting the very results which they are often charged as 
bringing about. 

Degrees of Ruptured Perineum. — First. Where the lacera- 
tion extends back from the posterior commissure toward, but 
not into the perineal centre. 

Second. Where the laceration extends from the posterior 
commissure of the vagina to the verge of the anus, but only 
involves the skin and subcutaneous cellular tissue. 

Third. Where the laceration extends from vagina to rec- 
tum, dividing not only the skin and fascia, but both the 
sphincter vaginse and sphincter ani externus, and in some 
instances the vagino-rectal septum with the sphincter ani 
interims. 

Fourth. Where the perineum is perforated by the head 
passing through the perineal centre, and leaving the sphincter 
of the vagina and the sphincter of the bowel unsevered. 

Results, — These will depend on the degree of injury. If 
it be only the division of the posterior commissure, it amounts 
to nothing ; but if beyond this, then every line entails some 
disqualification. Then follows a descent of some or all of 
the pelvic viscera. This displacement is often accompanied 
with irritability of the bladder, compelling the patient to 
pass urine very often ; dragging sensations, pain, and great 
weariness in the loins, and inability to walk without great 
inconvenience. Symptoms of indigestion will frequently 
appear, the appetite fails, bowels become distended with flatus, 
and a train of nervous troubles comes on apace. But there 
is still a greater calamity, before which all others sink into 



II LACERATION OF THE FEMALE PERINEUM. 

insignificance. It is present when the laceration involves 
the sphincters of the bowel, and perhaps the vagi no-rectal 
septum. All control over the intestinal contents is lost ; the 
feeces and gas pass incontinently ; the person is ever and anon 
soiled with the dejections ; the escape of wind from the 
bowel produces necessarily mortification ; a disgusting odor 
adheres to and emanates from the body ; friends shun her ; 
those who should cherish her, minister with reluctance to 
her necessities, and she is compelled to impose a seclusion 
worse than death itself. To rescue a patient from so dread- 
ful a prison-house, ranks among the noblest achievements of 
surgery. It not only blesses the miserable sufferer, but it is 
reflex. It makes the surgeon go on his way rejoicing, in the 
consciousness of being instrumental in the hand of God of 
doing so great a good. Such are the threads of gold which 
run through the complex mechanism of professional toil, and 
inspirit the heart amid so much calculated to weary and de- 
press. 

Deformity from Laceration. — When the laceration is slight, 
it only seems as though there was an unusual antero-pos- 
terior extent of the vulva. When, however, the muscles are 
severed, the departure from the normal appearance is very 
marked. The anal extremities of the labia majora are drawn 
widely asunder by the transverse perineal muscles, and curled 
upward by the contraction of the segments of the sphincter 
vaginae toward their origin aided by the anterior fibres of 
the levator ani. When the septum between the rectum and 
vagina is torn, the mucous membrane of the former often 
projects in redundant folds into and even above the fissure, 
also downward, resembling in some degree a prolapsus ani, 
which, indeed, it is, brought about by those fasciculi ^f the 
levator ani muscles, which influence the anterior portions of 
the sphincter, dragging them upwards when once disengaged 
from the perineal centre. These deformities increase by age, 
and the chasm grows wider until cicatrization is completed, 
when there is some little diminution. 

Prevention. — Every obstetrical writer devotes a portion of 
his chapter on the process of labor to the support of the 



ANATOMY OF THE FEMALE PERINEUM. 15 

perineum. This would seem to be a very natural and rea- 
sonable demand, but there is considerable discrepancy of 
opinion about it. There are not wanting those who deny 
entirely the necessity for such a precaution. Among the 
Germans, there are Sacombe, Faust, "Wigancl, of the older 
class ; and Mende (Beobachtungen und Bemerkungen aus 
der Geburtshiilfe und gerichtlichen Medizin, Gottingen, 
1825), who are entirely opposed to supporting the perineum. 
Mende declares nature provides all remedies against its in- 
jury. V. Siebold (in the Journal fur Geburtshiilfe, Bd. v., 
Hft. 1, s. 63) takes occasion to contradict and expose these 
views at some length. 

In France, Pinel Grand-Champ, Danyau expressed them- 
selves opposed to support, asserting that such was positively 
injurious. And in England, Thompson (Frorieps ]N"otizen, 
Bd. 7, No. 18, 1824) uses very similar language. In the 
latter part of the fourteenth century, Eros or Trotula, in the 
twentieth chapter of his book (de Passionibus Mulierum, 
quoted in I. Spachii Gynseciorum, etc., ed Argentina?, 1597, 
fol. 50), says, "Ad periculum evitandum (ruptura? puden- 
dorum) eis in partu sic providendum est : prasparetur pan- 
nus in modum pilse oblonga? et ponatur in ano ad hoc, ut in 
quolibet connatu ejiciendi puerum, illucl firrniter ano impri- 
matur, ne fiat hujusmodi continuitatis solutio." 

Eoder and Stein virtually agree with him, as they advise 
the insertion of two fingers into the rectum to guide the 
head in the proper direction. Schaffler (Hufeland's Journal 
der praktischen Heilkuncle, Bd. xiii., 3 St., 1802) recom- 
mends one hand placed on the os sacrum, and drawn, while 
pressing softly, toward the perineum, in order to gain more 
skin for the latter, at the same time, with the palm of the 
hand, to give the head an upward direction. "Wigand also 
recommends rubbing the skin upward from the thighs to- 
ward the genitalia. Such manipulations can be of very little 
use. Xedel, Stark, and Stein, Sr., counsel proper support 
with the hand and the use of fatty oils. 

Niemyer sustains the perineum in the hollow of the hand, 
leaving one inch back of the posterior commissure free, the 



16 LACERATION OF THE FEMALE PERINEUM. 

pressure to be made in the axis of the inferior strait. Bar- 
low advises support until the perineum is well distended, 
then allows it to take care of itself. BTedel places only his 
thumb across the fourchette (Vorschlag eiuer neuen verfah- 
rungsart die Ruptur des Perinaums bei der Geburt zu ver- 
hiiten und die Erfolgte zu heilen. Magdeburg, 1806, s. 51). 
The object of this method is to sustain the point only where 
usually the rent commences. 

Hohl recommends a particular method, placing the ends 
of four fingers on the foetal head, close to the posterior com- 
missure, and the thumb on the opposite side of the head, 
near the arch of the pubes, thus both restraining and guid- 
ing its delivery. There is certainly very little support fur- 
nished to the perineum by such a plan, but it is not without 
its value in preventing the too sudden expulsion of the child 
before the maternal tissues are prepared. 

Heine and M 'tiller counsel the side position as calculated 
to prevent rupture. 

Burns advises pressure, uniformly applied over the entire 
perineum, until the head passes, and particularly to the pos- 
terior commissure, charging the woman not to bear down 
during the presence of a pain. Mr. Burns evidently never 
passed through the throes of childbearing, or he would have 
omitted the last recommendation of the sentence ; not to bear 
down in such an extremity is simply impossible. 

Denman retards the head partly by pressure made directly 
against it, and partly by the hand planted against the peri- 
neum. The object here is to detain the head until the parts 
are sufficiently yielding. 

Hamilton so applies the hand that the part which sustains 
the greatest pressure shall receive the principal support. 
During the intervals of pain he directs the perineum to be 
rubbed with lard, and, when the head is emerging, to lay the 
fingers against the posterior part of the vulva, and pressing 
the perineum toward the pubes. 

Busch recommends the fingers being planted against the 
head, to prevent its being driven out too suddenly, and, when 
this is not likely to occur, to support the parts by placing the 



ANATOMY OF THE FEMALE PERINEUM. 17 

balls of the hand on the posterior commissure, the palm on 
the perineum, and the fingers along the sides of the anus; 
supporting only during the presence of a pain, and never 
strongly opposing the foetal advance. During the escape of 
the head and the retraction of the perineum the supporting 
hand should follow the latter carefully. He is unfavorable 
to using the uncovered hand. 

V. Siebold, during the intervals of pain, rubs the skin of 
the thighs toward the perineum, and during the presence of 
pain gives a very gentle support. He does not, as Busch ob- 
serves, sufficiently insist on uniform pressure. 

Carus says it is only necessary to give the posterior com- 
missure sufficient background by pressure. He evidently 
has in mind the old maxim, obsta jwincijnis. 

Mesnard thought it only necessary to push the coccyx back- 
ward, or place two fingers between the head and perineum. 

Pinel Grand-Champ says support is not only useless, but 
injurious. 

Mencle, of Gottingen, published the same opinion. 

Dr. Hodge enforces pressure, especially supporting the 
posterior commissure. 

Dr. Meigs enjoins the same, using a napkin supported by 
the hand. 

Ramsbotham uses a napkin as a matter of delicacy, main- 
tained against the perineum by the hand. 

Cazeaux employs the hand alone. 

Velpeau directs the hand to be wrapped in a napkin and 
placed transversely, the cubital edge toward the coccyx. 

What is to be done when, in consequence of the great size 
of the foetal head, or some unusual peculiarities of the peri- 
neum, its laceration becomes inevitable ? 

Michaeles (Lucina, Bd. vi., Hft. 1) recommends incisions 
in the perineum; and Siebold, in discussing this same sub- 
ject, insists the incisions should be made where there is least 
tension, or where the head presses least. 

Ritgen takes a similar view, but confesses there is such a 
repugnance to it in civil practice that he has not been able 
to do it. Neither has he done it in hospital service. 



18 LACERATION OF THE FEMALE PERINEUM. 

Blundell not only advocated, but practised slight incisions ; 
to be made laterally, and to be done during the presence of 
a pain. 

M. Paul Dubois also directs an oblique incision. 

Chaiily-Honore concurs in the same practice, believing that 
even should the incision become a laceration, its direction 
will be such as not to incur the disastrous consequence which 
ensue in a tear through the raphe. 

Dr. Simpson, of Edinburgh, advocates the practice. 

Dr. Penrose, Professor of Obstetrics in the Medical Depart- 
ment of the University of Pennsylvania, teaches the pro- 
priety of incisions in extreme cases. 

Dr. Wallace, of the Jefferson Medical College, thinks the 
necessity for such a course can scarcely arise. 

Dr. E. "Wilson, long connected with the Nurses' Home as 
a teacher of Obstetrics, opposes the practice as unnecessary. 

In speaking on this subject D'Outrepont objects to the 
operation, on the ground that this cut, once started, may 
soon be converted into a tear, extending even to the anus. 

Busch thinks these incisions should be confined to cases 
of organic anomalies only. 

The cases demanding such an operation must certainly 
be extremely rare, and the danger in inculcating it is, that it 
will be abused by practitioners of limited experience be- 
coming unnecessarily alarmed, and resorting prematurely to 
the knife. 

The accident may be prevented again by resorting to the 
forceps — a practice advocated by Moreau, Busch, and Hiitter. 

The employment of ether or chloroform will conduce to 
the preservation of the perineal structures by the relaxation 
which is secured, and also by rendering the patient insen- 
sible to that acute suffering which provokes the violent con- 
tractions of the perineal muscles. 

I think, from all that has been quoted, we may conclude 
the perineum demands support as a precautionary measure. 
That the bare hand is the proper support, as it communi- 
cates to the mind information which could never be per- 
ceived through an interposed napkin, and should not be 



HISTORY OF LACERATED PERINEUM. 19 

applied too early. That the degree of pressure should be 
properly graduated and regulated by the necessities of the 
case, and only made during the existence of pain, and the 
direction, so as to prolong the curve which coincides with 
the axes of the straits. To this end, the palm of the hand 
should be applied against the perineum, so that the balls 
of the thumb and little finger shall rest just in front of the 
anus, and the fingers on the posterior commissure of the 
vulva. Thus adjusted, the pressure should be, at first, firm- 
est posteriorly, so as to deflect the head toward the pubic 
arch, and then, during its exit, well and securely applied to 
the posterior margin of the vulva. 

History of Lacerated Perineum. 

There is a grand ongoing in all human history. And in 
no department of science or art is the march more rapid 
than in our own. IsTo physician imbued with the true spirit 
of his profession can fail to be interested in tracing the 
progress of a great surgical problem through all the stages 
of supposition, experiment, and fact. Snch a study will in- 
crease greatly our faith in this noble calling, and moderate 
surgical dogmatism. A sound surgical mind will be ex- 
ceedingly cautious in asserting impossibilities. The experi- 
ence of the last fifteen years goes to add significance to this 
observation. The methods of cure may be arranged under 
two heads — Position and Suture. 

Lacerations about the perineum did not escape the notice 
of Celsus, but he had no remedy except securing the limbs 
together and enjoining perfect rest. 

Ambrose Pare recognizes the injury, and recommends 
the use of sutures. The same may be said of Mauriceau, 
but there is no evidence on hand to show either had ever 
employed them. The first recorded case of operation, is 
that of Guillemeau (Surg., page 354, chap. viii.). The rent 
occurred in a former labor, and was of an aggravated kind, 
extending through the whole length of the perineum, and 
laying both cavities into one. This case must have in- 
spired all future operators. The edges were pared alike — ■ 



20 LACERATION OF THE FEMALE PERINEUM, 

not cutting much flesh, but principally skin and fascia — a 
needle was passed through the sides of the wound, and a 
thread wrapped about it, by which the parts were drawn 
together. This formed the twisted or hare-lip suture. He 
next inserted several interrupted sutures, and in fifteen days 
the case was cured. As G-uillemeau was a pupil of Pare's, 
it is probable he received from his master the hints, which, 
in this case, were reduced to practice. The valuable work 
of Busch and Moser contains an excellent article on the 
plans of various authors. 

Among those who advocate position alone are to be found 
many distinguished names. (Thymoeus Collect, de Peonet, 
tome iii., page 96. Peu, Pratiq. des Accouchemens, page 
422.) 

These parties assert that complete ruptures, by which is 
meant lacerations extending to the anus, heal without any 
treatment. De la Motte, however, does not seem to repose 
implicit faith in their assertions, as he mentions one of their 
cases which did not heal. 

Deleurye (Traite des Accouchemens, page 320) agrees with 
the above authors, in some degree, saying large ruptures can 
be cured without any suture : and to the same import is the 
language of Puzos (Traite des Accouchemens, page 134). 
" These wounds," says our author, " can be cured as well by 
approximating the thighs as by sutures." 

Aitken (Principles of Midwifery, 1788) rejects sutures al- 
together. 

D'Outrepont says extensive lacerations heal spontane- 
ously by position ; and such is the opinion of Busch and 
Moser. Besides these may be mentioned Paletta, Exercita- 
tiones Pathologicge, pars, ii., Mediolani, 1826. Gardieu 
Traite complet d ? Accouchemens, torn. iii. (Sedillot, Recueil 
periodique de la Societe Medicale de Paris, torn. iv.). Boyer 
and M. Duparcque (the latter the author of the paper pub- 
lished in Paris in 1836, entitled Histoire complete des Rup- 
tures et des Dechirures delTIterus, du Vagin, et du Perinee). 
To these may be added the name of Dr. Waller, who de- 
clares having seen ruptures traversing the entire perineum, 



HISTORY OF LACERATED PERINEUM. 21 

and laying both cavities into one, get well, and the control 
over the intestinal contents return ; no treatment having 
been adopted but position and cleanliness. And not only 
so, but goes further and states, " most cases which have come 
under my observation have done well." It would have been 
more satisfactory had he defined his understanding of the 
term " done well" An injury to the extent just stated can 
never do well. 

Blundell thinks there is little to be hoped from operations, 
failure being the rule ; and the same testimony is furnished 
by Dr. Davis. Eamsbotham describes the injury, but as he 
indicates no treatment, it is not probable he viewed the su- 
ture with favor. 

Dr. Cockle, in a paper published on Laceration of the 
Perineum, in 1853, as quoted by I. Baker Brown, advises 
against sutures, especially in the early stages. 

The Suture. — The advocates for suture are both numerous 
and respectable, among whom we may name Moreau and 
Smellie, neither of whom, Busch says, ever performed it, al- 
though it received their sanction. De la Motte (Traite* com- 
plet de Accouchemens, page 761, Obs. 401). Also Morlanne 
(Journal des Accouchemens, torn. i. p. 188). Saucerotte (Jour- 
nal general, torn. iv. p. 417). Noel (Idem, torn. vii. p. 187). 
Montain (Idem, torn, lxxvi. p. 140). Mayo (London Medical 
and Physical Journal, September, 1828). Bond (The Lon- 
don Medical Eepository, etc., by GT. M. Burrows, No. 128, 
August, 1824). Churchill (Idem, No. 126, June). Alcock 
(The London Medical and Physical Journal, vol. xliv., Sep- 
tember, 1820). Payer (Edinburgh Medical and Physical 
Journal, No. lxxvii., October, 1823). Campbell (Idem). Zang 
(Darstellung blutiger heilkunstlicher Operationen, iii. Th. 
1, Abth.). To this list we may add, Osiander, Williams, v. 
Fabrice, Pitgen, Meissner, Langenbeck, Poyer, Hafer, Mer- 
cogliano. D'Outrepont, Dupuytren, Pauley, Poux, and Dief- 
fenbach, all of whom record cases with good results by the 
suture. Poux asserts there never was a case of satisfactory 
cure if left to nature (Gazette Med., 1834, p. 18). His method 
consisted in approximating with quilled sutures, aided by 



22 LACERATION OF THE FEMALE PERINEUM. 

interrupted ones at a few intermediate points, and the use 
of semilunar incisions where there was much strain on the 
sutures. Duparcque says no union, in a proper sense, can 
occur unaided. 

Chelius may be named as an advocate for the suture ; also 
Menzel, Wutzer, M. Verheeghe, and Kilian. Velpeau recom- 
mends the suture and Dieffenbach's incisions. Chelius (vol. 
ii. p. 38), while he favors an operation, thinks the conse- 
quences are very uncertain, and on page 39 of the same 
volume, the editor, Mr. South, records a successful case by 
Dr. Davidson taken from the pages of the Lancet, 1838-9, 
vol. ii. The suture used was the quilled, and to counteract 
the tendency to e version, the gum cylinders were drawn to- 
ward each other by a piece of tape. Roux, in order to cor- 
rect this effect of the quilled suture, inserted a few inter- 
rupted oues. 

Burns (Principles of Midwifery, vol. i. p. 58, edition 1820) 
recommends sutures strongly, when reunion cannot be 
effected by other means ; although the American editor, 
Prof. James, in a footnote on same page, says they (sutures) 
should rarely be had recourse to, as they give great irrita- 
tion. I. Baker Brown incorrectly states Burns makes no 
mention of the accident. 

Dieffenbach, in 1829, turned his thoughts to rupture of the 
perineum, and after a thorough contemplation of the entire 
ground, concluded these accidents ought not to be left to 
nature. The substance of his conclusions may be summed 
up briefly as follows: Immediate operations; the use of 
either the twisted or interrupted sutures ; in secondary ope- 
rations, the edges being previously well pared ; semilunar 
incisions on either side, when the approximation makes 
much strain on the sutures ; transplantation in cases attended 
with great loss of substance ; opium in sufficient amount to 
keep the bowels bound for several days, and the removal of 
the urine by the catheter as occasion may requiue. 

I^evermann (in a German translation of Duparcque), 
having noticed that stonemasons, receiving lime into the 
eye, in twenty-four hours had the lids and ball adherent, 



HISTORY OF LAOERATED PERINEUM. 23 

suggested that the margins of a laceration should be sub- 
jected to a similar treatment by applying quicklime, and 
then securing the limbs together. 

Langenbeck, with his usual ingenuity, presents us with a 
method which is termed perinceo synthesis, the description 
of which is given by M. Verheeghe, of Ostend (in his Me- 
moire sur un Nouveau procede Operatoire pour la Guerison 
des Ruptures Completes du Perinee, Bruxelles, 1852). This 
monograph I have not been able to peruse, but glean the 
leading features of the plan from I. Baker Brown's excellent 
treatise on rupture of the perineum. The first step consists 
in freshening the free border of the recto-vaginal septum ; 
next, splitting the septum, the anterior layer of which is 
designed, after the laceration is united, to be brought down, 
and stitched by its angles, to the front part of the newly 
joined perineum, thus protecting the parts against the vagi- 
nal discharges. After this, the edges of the laceration are 
pared, extending forward to the posterior commissure of the 
vulva, avoiding the mucous membrane of the vagina. Then 
comes the approximation. After the cessation of bleeding, 
the rectum is first closed by a suture, inserted with Wutzer's 
curved needles ; then the perineum by interrupted and 
twisted sutures, and lastly, the attachment of the anterior 
part of the septum. To relieve tension, he employs the in- 
cisions of Dieffenbach, directs vaginal injections of an infu- 
sion of chamomile, catheterism, low diet, and opium in suf- 
ficient quantities to maintain constipation until after the 
removal of the sutures. 

Bernard and Huette (Operative Surgery, page 454) are 
very brief, recommending position, if the case is recent ; if 
old, vivifying the edges, uniting by the quilled suture, as 
practised by Roux, and making the Dieffenbach incisions if 
demanded. The} 7 state the threads should be allowed to re- 
main until complete cicatrization takes place, union by the 
first intention not being~expeeted. 

Guerin (Chirurgie Operatoire, page 578) approves of 
Roux's operation with Dieffenbach's incisions. 

Sedillot (vol. ii. p. 441) reiterates the same views. 



24 LACERATION OF THE FEMALE PERINEUM. 

Viclal (Pathologie Externe, tome v. p. 755) speaks favor- 
ably of Poux and Dieffenbach's methods ; and so also Du- 
gere (Des Dechirures du Perinei, 1856). 

C. Clay, speaking of the accident, in 1856, advises quilled 
sutures, catheter for twelve or fourteen days, rest and cleanli- 
ness. The sutures, he says, should be removed the seventh 
day. 

Miller (Princip. Surg.) treats the subject with great brev- 
ity, but is not adverse to operations. 

Skey, in his Operative Surgery, (1858) makes no very en- 
couraging allusion to the subject, but recommends the oper- 
ation of Brown. 

Holmes's Surgery, vol. iv., has an article on ruptured per- 
ineum, written by Mr. Hutchinson. He recommends an im- 
mediate operation and position ; observing, that even should 
the lochial discharge and bruised condition defeat the heal- 
ing, occasionally, nothing will be lost by the attempt. "Where 
the sphincter ani is torn, he thinks relief from incontinence 
may be promised, but not so surely that from prolapsus of 
the uterus. A great deal, he says, depends on extensive 
denudation, so as to have a deep mass to support the pelvic 
viscera. The sutures recommended are either the quilled, 
or what he likes better, a perforated metal bar, with wires 
passed through, on the ends of which are clamped shot, and 
secured by being twisted round cylinders of wood. He also 
advises dissecting up from the septum a flap consisting of 
mucous membrane, after Langenbeck or Fricke, and bring- 
ing it down to be attached to the restored perineum. The 
sutures he removes the sixth or seventh day. 

M. Jobert (De la Reunion en Chirurgie, 1864) advocates 
the use of what he terms the serpentine suture, to be formed 
out of silk thread, and inserted by curved needles. The 
description is not clear. 

There is, however, one name among British surgeons 
prominently associated with this subject ; it is that of I. 
Baker Brown. His experience in the treatment of injuries 
of the perineum has unquestionably been greater than that 
of any other surgeon. Prom 1853 to the present time his 



TIME FOR OPERATION. 25 

eases have been accumulating, until they number, as pub- 
lished in the last edition of his book, 1866, 112 cases, 104 of 
which were cures. So completely has the operation been 
vindicated, that no treatise on surgery, recently published, 
fails to devote a chapter to lacerated perineum. 

The leading features of Baker Brown's operation are ex- 
tensive denudation; quilled sutures, with interrupted ones ; 
division of the sphincter ani on each side, and keeping the 
bowels qniet with opium. 

Among American writers, it may be said very little atten- 
tion has been given to the subject. No allusion is made to 
the injury either in the works of Dorsey or Gibson. Prof. 
H. II. Smith (Smith's Surg., vol. ii. page 555) describes the 
accident and its treatment, adopting the plan of Baker 
Brown. 

Dr. Mettauer, of Virginia, published a remarkable case 
(American Journal of Med. Sciences, vol. xiii. p. 113, 1833), 
in which the rent extended three inches up the rectum. 
The edges were properly vivified, and closed by leaden 
sutures. 

Prof. W. E. Horner (Am. Journal Med. Sciences, vol. xx. 
p. 329, 1850) furnished the history of a severe case of lacer- 
ation, attended with such loss of tissue as to induce him to 
undertake the relief of the patient by raising two flaps from 
the contiguous parts, and, turning them on their bases, 
united them across the chasm. This case, as related by Dr. 
Smith, although not cured entirely of incontinence, was 
much benefited. 

Prof. Gross (Gross's Surgery, vol. ii. p. 1051) treats of the 
subject, agreeing in the main with the plan of Baker Brown, 
except in the particular of dividing the sphincter, which, he 
says, he has never found necessary to do. 

Time eor Operation. 

The operation is divided into primary and secondary. By 

the term primary is meant the employment of the suture at 

a period when the surfaces are raw from laceration, by the 

term secondary, at any period when the knife is required 

3 



26 LACERATION OF THE FEMALE PERINEUM. 

to freshen the margins of the laceration. If the case is one 
demanding sutures, the sooner they are inserted the better. 
Tf called at a period when, in consequence of the extreme 
distension, the parts are cedematous, contused, and threaten- 
ing gangrene, it is thought best by many to avoid the suture. 
If, however, the metallic thread is used, I do not see any 
objection to its application, even under such unfavorable 
local conditions. Should only a few points of adhesion be 
secured, it is a positive gain, the rest may granulate. Those 
who object to primary or immediate operations allege, first, 
there is danger of vaginitis or metritis ; second, the lochial 
discharges diffusing themselves over the parts prevent heal- 
ing ; and third, cases make a good recovery when a proper 
position is maintained and the process left to nature. 

With regard to the first the dangers apprehended are for 
the most part imaginary. If the metallic thread be used, 
there is really less irritation and suffering than if left un- 
touched, because the exposed raw surface is almost com- 
plete^ closed. And for the same reason the second objection 
is answered, inasmuch as an accurate adjustment precludes 
in a good degree any prejudicial effects from the lochial 
flow. The last objection rests on a peradventure, and puts 
the exception before the rule. Nature, unaided, in the large 
majority of cases, makes but a sorry restoration of the peri- 
neum. The retraction which the muscles undergo before 
and during the slow progress of granulation and cicatriza- 
tion, diminishes very much the proper execution of their 
functions ; and hence the value of immediately introducing 
the suture. 

"When the primary period has passed, and the secondary 
operation becomes necessary, the question arises, when should 
it be done ? In general we say, whenever the patient's gene- 
ral health is well established and the parts thoroughly healed, 
sound and free from all inflammatory and suppurative action. 
It is imperative that such should be the case, otherwise the 
tissues will not sustain the pressure of the suture. This will 
demand ordinarily two or three months, but if it even should 
require a year or more, it must not be disregarded. 



PREPARATION OF THE PATIENT. 27 

Is it impossible to undertake an operation during gesta- 
tion? Such, until recently, has been the opinion of most 
surgeons. They have supposed that, during this period, the 
attractive forces concentrated upon the uterus and its asso- 
ciate organs would defeat the healing process in the peri- 
neum. This view is not sustained by facts. The cure may, 
therefore, be undertaken during the early months of preg- 
nancy ; that is to say, antecedent to the fourth month. Such 
is the opinion and counsel of Baker Brown, who says, in no 
instance in which he has operated, have there arisen any 
symptoms threatening miscarriage. 

Beyond this period there are two reasons rendering it im- 
proper to undertake an operation. First, the reflex influ- 
ence, inviting uterine contractions and endangering the safety 
of the embryo ; and second, the time is too short to secure to 
the perineal components the requisite physical and vital pro- 
perties of elasticity and contractility, so as to run no risk of 
a second laceration. 

The menstrual flow constitutes another contraindicating 
circumstance. The third or fourth day after its cessation is 
the favorable period. The presence of a catarrhal attack, 
accompanied with cough or sneezing, is of sufficient im- 
portance to defer any operative measures, as the antagonism 
which exists between the diaphragm and perineum would be 
the means of greatly disturbing the dressings. There are 
some, among whom may be named Eoux, who oppose opera- 
tion while the mother is nursing. The same counsel is given 
in cases of vesico-vaginal fistula, under a belief that there is 
great danger of subsequent pyaemia. I have not regarded, 
this caution in cases which have come under my own care, 
and in no instance have I seen any unpleasant results. 

Preparation or the Patient. 

"Whenever the surgeon assumes the management of such a 
case, the condition of the- different organs should be carefully 
inquired into. He will often find such patients suffering from 
diarrhoea, disturbance of the digestive organs, and a train of 
distressing nervous symptoms. To correct these, a properly 



28 LACERATION OF THE FEMALE PERINEUM. 

regulated diet, fresh air, the subnitrate of bismuth, together 
with tonics, either vegetable or mineral, are necessary. 

The medical attendant should discountenance the habit of 
taking laudanum, opium, or other narcotics, in order to keep 
the bowels costive. A patient cannot continue to do so long 
with impunity. The digestion will be, sooner or later, im- 
paired. It is much better to secure consistent stools by a 
careful study of the food. An animal diet, with stale bread, 
boiled milk, and a very moderate allowance (if any) of vege- 
tables, will usually effect this result. Thirty-six hours 
before the operation the bowels should be emptied by a 
gentle cathartic, such as castor oil, after which a sufficient 
amount of opium should be administered to render them 
quiet. The hair is to be removed from the parts, and a very 
moderate amount of food taken the morning of the day ap- 
pointed for the operation, so as in no way to interfere with 
the anaesthetic. 

The bed on which the patient is to lie should be a firm 
mattress, protected by a piece of oil-cloth, over which may be 
spread a folded sheet. 

Operation. 

Assistants. — To have every appointment consummated in 
the most satisfactory manner, there should be not less than 
four assistants, although three will answer ; one to take charge 
of the anaesthetic, one to support either lower extremity, and 
one to attend to the sponges and instruments which may be 
required by the surgeon. 

Position. — Three positions have been advised. 

First, On the side, with the nates brought over the edge of 
the bed and the thighs strongly flexed on the body. This 
is the position recommended by Busch and Moser, and they 
claim for it complete relaxation of the perineal tissues and 
less risk of cold, as there is very little of the person unpro- 
tected hy clothing. 

Second. The kneeling posture, the body well bent forward. 

Third. The dorsal position, the patient resting on the back, 
the hips projecting over the side of the bed ; the legs flexed 



OPERATION, 



29 



Fig. 



on the thighs, and the thighs on the abdomen : this is the 
lithotomy position. 

The one preferred by most operators, and which is unques- 
tionably superior to all others, is the third. It offers in every 
respect the best control of 
the parts. Fi «- 3 - Fi -^ 

Instruments. The instru- 
ments required are few 
and simple. An ordinary 
scalpel (Fig. 8) ; a pair of 
my long-bladed forceps, 
with an adjuster at one 
extremity (Fig. 4) ; three 
or four good-sized needles 
to insert the more super- 
ficial or secondary inter- 
rupted sutures ; a needle 
supported on a handle 
(Fig. 5, Fig. 7), to intro- 
duce the deep or primary 
sutures; iron wire, coat- 
ed with silver, perforated 
shot, shot compressor and 
scissors (Fig. 6) ; tenacu- 
lum, silk ligatures, and 
sponges. Such comprise 
the list of instruments re- 
quired for the execution 
of the operation. Should 
the method of Baker 
Brown be preferred, there 
will be wanted a blunt or 
probe-pointed bistoury to 
divide the sphincter, and 

pieces of cane or elastic bougie, together with waxed twine, 
to form the quilled suture. 

Immediate or Primary Operation. — If the accident is discov- 
ered immediately after its occurrence, it should be promptly 




30 



LACERATION OF THE FEMALE PERINEUM. 



treated with the suture within twelve hours. Simple ap- 
proximation by position is not reliable. The number of 



Fig. 6. 



Fis. 7. 




Fig. 7 — 1. Needle for introducing the deep sutures. This I have had modified, 
making it a more useful instrument. It consists of two parts, the holder and the 
needle. 2 and 3 give two views of the needle. The lower extremity is square, with 
a notch, designed to fit into the shank 4, either at its extremity, so as to be in a line 
with the handle, or at a right angle, and secured by a spring which sinks into the 
notch. 

sutures will be determined by the extent of the laceration. 
The advantages of such a coarse will be apparent, when it 
is considered the perineal tissues are flaccid in consequence 
of the extreme extension to which they have been subjected, 



OPERATION. 31 

and, therefore, there will be little strain on the threads. 
Again there is an innate tendency in the parts to heal when 
thus immediately adjusted. The mode of using the suture 
will be explained under the head of the secondary operation. 
The parts must be kept perfectly clean, being frequently 
bathed with a solution of the permanganate of potash, and 
all the subsequent treatment carried out in the manner de- 
scribed hereafter. 

Secondary Operation — The 31ethod of I. Baker Brown. — The 
woman being placed in the lithotomy position, and the parts 
carefully shaven, an assistant gives the requisite tension to 
the sides of the laceration, while the surgeon pares away the 
parts half an inch external to their edges, and sufficiently 
deep to reflect inwards the mucous membrane. The recto- 
vaginal septum must also be carefully freshened. The next 
step consists in dividing the sphincter ani on both sides about 
a quarter of. an inch in front of its coccygeal attachment. 
This is done by a blunt-pointed bistoury, conducted by the 
finger within the margin of the anus, and then pressed 
through the tissues to the extent of one or two inches ex- 
tenia! to the anal opening, and through the more superficial 
fasciculi of the muscle, leaving the deeper portion undis- 
turbed. Dr. Van Buren paralyzes the sphincter by extreme 
extension. The third stage comprises the insertion of the 
sutures. For this purpose a strong needle, armed with a 
double thread, is passed through one side, entering one inch 
external to the edge and coming out at the termination of 
the denuded surface, after which it is made to traverse the 
opposite side, entering and emerging at points correspond- 
ing to the first. Each suture is to be inserted in the same 
manner, the one nearest the anus always first. The needles 
used for this purpose, I presume, are such as are figured in 
Dr. Brown's book, and a representation of one of which is 
seen in Fig. 5. 

The threads thus passed present loops on one side and free 
ends on the other. Two pieces of cane, or elastic bougie, are 
next placed in position, one piece passed through the loops, 
and the other laid between the free ends, and both parallel 



32 



LACERATION OF THE FEMALE PERINEUM. 



with the wound. The approximation is effected by pressing 
the sides of the laceration together and tying the free ends 
securely around the cylinder which lies between them. 



Fie:. 8. 




Introduced from I. Baker Brown's book, with a view to exhibit the pared edges, the 
quilled sutures in position, and sphincter divided on each side. 

To prevent eversion of the edges, a result of the quilled 
suture, interrupted metallic sutures are inserted between the 
others. Langenbeck and Verkseghe employ for this purpose 
the twisted or hare-lip suture. Before closing the operation 
one finger should be carried into the vagina and another into 
the rectum, in order to ascertain the accuracy of the adjust- 
ment. The parts are next cleansed ; a piece of lint, wet with 
cold water, laid over the parts ; upon this a folded napkin ; 
tke wkole secured by a T bandage. The urine is to be drawn 
every four or six hours for four or five daj^s, or an elastic 
catheter maybe placed in the bladder and allowed to remain 
for twelve or fourteen hours, the free end being placed in a 



OPERATION. 



33 



liquid-proof bag to receive the urine. One grain of opium 
is immediately given, and repeated every six hours for the 
first twenty-four ; afterwards one grain night and morning. 
Fig. 9 exhibits the parts closed. 



Fig. 9, 




The diet is to consist of milk, arrow-root, beef-tea, mutton 
chops, and, if required, port wine. 

Forty-two hours after the operation the deep sutures should 
be removed, and the superficial ones about the seventh day. 

The opium is to be continued, so as to keep the bowels 
constipated for two or three weeks after the parts have united, 
after which they may be moved with castor oil and enemata 
of warm water. 

In this method of Baker Brown it will be found, on re- 
viewing the historical part of our article, there is nothing 
new. The quilled suture had been used over thirty years 
ago by Eoux, Davidson, and others. Incisions of the skin 
and subcutaneous tissues had been inaugurated by Dieffen- 



34 LACERATION OF THE FEMALE PERINEUM. 

bach ; of the sphincter muscle by Saucerotte ; and the use of 
opium to constipate the bowels had been taught by Dieffen- 
bach and others. The particular point and direction at which 
the sphincter is divided belongs, however, to Baker Brown ; 
and not only so, but by combining all these peculiarities 
into a method, and illustrating their value by a record of 
cases greater than any other man, he has done a great work 
for surgery, and gained a strong hold over the mind of the 
American profession. 

Author's Operation. — In every operation our aim should be 
to render it as simple as may be consistent with efficiency ; 
and, therefore, the question comes up, can any part of the 
Brown method be omitted without diminishing the value of 
the operation? In support of the affirmative, I submit the 
plan pursued by myself, and illustrated by a sufficient number 
of cases to give it some claim to public confidence. 

Preparatory Treatment. — This is pursued in accordance with 
that already laid down, except in the matter of opening the 
bowels with a gentle cathartic, which I prefer being given 
very early the day before the operation, and followed by one 
or two grains of opium, so that no fseces shall descend into 
the rectum, and everything be quiet when the period comes 
round. 

Position. — The position on the back, or the lithotomy posi- 
tion, is the one always preferred. The hips should be brought 
over the edge of the bed, and the limbs, flexed, should be 
supported by an assistant on either side. 

Operation. — The operator takes his position, either sitting 
or kneeling, in front of the perineum, and seizing one side 
of the laceration, commences the denudation from behind 
forward, including a little of the labium. In breadth it 
should extend inward, so as to include a little of the vaginal 
mucous membrane, and outward towards the buttock. The 
paring should not extend deep, but merely skim the surface, 
and, when completed, should be over one inch broad. The 
opposite side is to be treated in the same manner, the raw 
surfaces in form and extent being as near alike as possible ; 



OPERATION. 35 

next, let the assistants supporting the limbs take hold of the 
parts on either side, and make the recto-vaginal septum tense, 
in which condition its surface can be freshened, without 
difficulty, to the extent of three-quarters of an inch, or the 
operator may insert his finger into the rectum and make it 
sufficiently tense, using the scissors to freshen. Let every 
attention be given to ascertain no portion escapes the knife. 
The bleeding is usually free, but it will be seldom necessary 
to apply a ligature. Should it not cease under the application 
of ice-water, a stream from the nozzle of a syringe, applied 
steadily for some time, w T ill rarely fail. Should both fail, 
introduce the sutures, and rely on the adjustment. 

Sutures and their Introduction. — The approximation is to be 
effected by the interrupted suture — one series termed the 
deep, and the other the superficial — the materials composing 
the thread being iron wire, coated with silver. As every- 
thing depends upon the proper disposition of the first thread, 
I prefer iron wire, in order that it may not break. The deep 
ones are to be first introduced, commencing with the posterior 
or one next to the rectum. Three or four of these will gene- 
rally suffice, even in extensive cases. The superficial ones 
are to be inserted intermediate to the others. 

The first stitch. — The needle is threaded with the iron wire 
and entered three-quarters of an inch from the margin of the 
wound, below its lowest point at the anterior part of the 
ischio-rectal fossa, and carried forwards and upwards until it 
appears on the middle of the septum, just above the line of 
denudation; the thread is then pulled out of the eye of the 
needle, the latter withdrawn, and made to pass unarmed 
through the corresponding parts on the opposite side, emerg- 
ing on the septum, close to the first. The wire is now passed 
through its eye, and as the needle is withdrawn, makes the 
complete circuit of the wound (see Fig. 10), so that when it 
is tightened, the parts are pursed together. Three other 
deep equidistant sutures are inserted, and then comes the 
approximation. 

Adjustment. — The blood being carefully sponged away, the 
nates are to be pressed toward each other by the assistants, 



36 



LACERATION OF THE FEMALE PERINEUM. 



and the ends of the suture first introduced (the one nearest 
to the anus) are to be passed through the hole in the adjuster, 
at the end of the forceps, and being strongly drawn upon as 
the latter is carried down, the parts are brought together 

Fig. 10. 




Represents the parts freshened and the sutures inserted, ready for the approxima- 
tion. The point of entrance and exit of the first suture should have been shown \ inch 
lower down. 

with great accuracy. To maintain and secure the approxi- 
mation, a perforated shot is next run down over the wires, 
and firmly clamped between the jaws of the compressor. 
After the treatment of the other sutures in a similar man- 
ner, the operator proceeds to deposit the superficial threads. 
These must be placed between the others, to effect which a 
good-sized curved needle, armed with a silver wire, is en- 
tered three-eighths of an inch from the edge, on one side, 
made to penetrate the skin and some little into the cellular 
tissue, and emerge an equal distance from the edge on the 
opposite side. These may be secured by twisting the ends 
about each other. This done, the sutures are to be cut off — 



OPERATION. 



37 



the superficial ones at the twist, and the deep ones on a level 
with the shot. I have performed the operation omitting 
the superficial sutures, and with entire success. 

The appearance presented by the parts when thus adjusted, 
is well seen in Fig. 11. 

Fig. 11. 




A strip of adhesive plaster, two and a half inches wide and 
twelve or fourteen inches long, may now be placed across the 
nates, to give additional support, and the woman put to bed, 
with the knees bound together with a roller, taking care to 
interpose a napkin between, to prevent excoriation. The 
position to be maintained is either on the back or the side, 
the patient not being rigidly confined to either. 

After-treatment. — As a matter of primary importance the 
bowels are to be kept xjuiet, and to this end, opium must 
be administered in sufficient quantities to effect the object. 
Half a grain three or four times a day will usually answer. 
The urine must also be drawn mornins: and evening: or oftener 



38 LACERATION OF THE FEMALE PERINEUM. 

if the state of the bladder demands it. Should the nurse not 
be able to use the instrument — and the patient be at such a 
distance as to render it inconvenient for the surgeon to make 
frequent visits, then, a relf-retaining catheter with a piece of 
gum tubing attached may be worn, and the end passed into 
a vessel. After four or five days the patient may turn care- 
fully over upon her breast and pass the urine into a bedpan, 
dispensing altogether with the use of the catheter. 

Generally I have found it most convenient to use a male 
gum catheter guided by the finger to the urethra, as the in- 
strument has to be passed the patient being on the side. 

Should the patient be annoyed by painful accumulations 
of flatus in the rectum, it may be removed by carefully in- 
troducing a female catheter into the bowel. 

Diet. — This should consist of milk, beef essence, soft-boiled 
eggs, meat once a day, tea, coffee, and wine. 

Removal of Sutures. — On the seventh day after the opera- 
tion, all the sutures should be removed, commencing with 
the anterior one and proceeding back, the reverse of their 
introduction. In accomplishing this, the wire is cut on one 
side of the shot, then the curve or hook at its end straight- 
ened, to prevent scratching, and finally, the loop drawn 
away by pulling on the shot while pressure is being made 
against the thread so as not to allow its cutting into the flesh. 
Should the suture next the rectum be found well in place and 
no cutting or ulceration, it may be permitted to remain 
another day. 

Baker Brown recommends the removal of the deep sutures 
forty-two hours after their insertion, and the superficial 
sutures not to be disturbed for four days longer. 

On the second or third day the hips of the patient — lying 
on the side — are to be brought over the edge of the bed — a 
piece of oil- or rubber-cloth being interposed — so as to reach 
into some vessel, and then a stream of tepid water, contain- 
ing a solution of the permanganate of potash, thrown upon 
the parts with a syringe. The effect of this is always very 
grateful to the patient, and exercises a good influence over 
the healing process. This is to be repeated every day. On 



OPERATION. 39 

the eighth or tenth clay the bowels may by opened. This is 
to be accomplished with the greatest care. A teaspoonful of 
oil, or some saline should be give every five or six hours, and 
when the feelings of the patient indicate the near approach 
of a stool, the utmost caution is to be observed in securing 
its evacuation. The nurse should be directed to support the 
nates, the patient to avoid any great straining afforts, and if 
necessary the contents of the rectum may be softened by 
throwing into the bowel very gently a little tepid water. 
It may happen that the rectum becomes impacted with a 
large fecal mass, the expulsion of which would certainly 
tear asunder the tender line of union ; and then it is proper 
to core the mass, by picking a channel through its centre 
and enlarging this opening until its peripheral walls fall to- 
gether, allowing its safe expulsion. Once opened, the bowels 
should be locked up again four or five days, in order that 
the cicatrix may become solid. And it may be well for a 
few times to observe the caution of having the evacuations 
in the recumbent position. If everything has progressed 
favorably, the patient may be allowed to sit up after the four- 
teenth or sixteenth day. 

In cases where the recto-vaginal septum is torn to any con- 
siderable extent it is thought by some to be necessary to 
modify the operation. The borders of the chasm must be well 
freshened, and brought together by silver threads, passed 
transversely by means of short, slightly curved needles, and 
their ends cut off close. This completed, the resoration of the 
perineum may be next executed. In the first case of this 
nature which came under my care, two operations were done 
at an interval of four weeks, the first to close the septum 
between the two canals and the second to restore the perineum. 
By the method described there is no necessity for this delay; 
both are done at a single operation. 

Report of Cases treated by the Interrupted Silver Suture alone, 
and without division of the Sphincter Ani. 

Case I. — Mrs. , set. 22, from Kentucky, during her 

first labor had the perineum torn, not only dividing the 



40 LACERATION OF THE FEMALE PERINEUM. 

sphincter ani, but extending up the vagino-rectal septum 
over half an inch. Her parturition was difficult and pro- 
longed, extending over thirty-six hours, and requiring instru- 
mental delivery. Two operations had been performed for her 
relief without success before her arrival. She was a lady of 
delicate organization, with not much muscular tone, and her 
health not well established when arriving in the city. Her 
disability was of such a character as to render her incapable 
of exercising control over either flatus or feeees. At the re- 
quest of Dr. Wilson, under whose care she had been placed 
for professional aid, I was asked to examine the case, with a 
view to determine what could be done for her relief. It was 
concluded that a short time should be employed in improv- 
ing, as far as possible, the health of the patient by appropriate 
diet and mineral tonics, after which, an operation should be 
done to close up the vagino-rectal septum, and afterwards, a 
second, to reconstruct the perineum. After the lapse of two 
weeks, it was deemed proper to proceed with the operation. 
The day previous the bowels were opened, after which an 
opiate was administered. The patient, being etherized, was 
placed on her back, the hips being brought to the edge of the 
bed, and the limbs, flexed, given to assistants, one on either 
side. A Sims speculum was next introduced into the vagina, 
drawn towards its anterior wall, and intrusted to one of the 
assistants supporting the limbs. The edges of the vagino- 
rectal septum were now seized with a pair of long, rat- 
toothed forceps, and freshened, each in its entire length, 
making the raw surface as extensive as possible. The hemor- 
rhage was trifling. Five silver threads were next inserted 
transversely, introducing the upper one first, and twisting 
together the ends of each suture, to prevent the different 
threads from becoming entangled. Next followed the ad- 

CD O 

j ustment, by passing successively the ends of each wire 
through the adjuster at the extremity of the forceps, and 
drawing on them as the latter was pressed down on the 
wound. The set thus given to the wire sufficed temporarily 
to retain the edges in close proximity, and then, to secure 
permanently the approximation, a perforated shot was run 



REPORT OF CASES. 41 

down over each thread and clamped by being compressed 
between the blades of the compressor. The wires were next 
cut off close to the shot, and the patient placed in bed upon 
her back. The urine was removed, morning and evening, 
from the bladder, and the bowels kept quiet by the exhibition 
of half a grain of opium, twice daily ; the diet to consist of 
cream toast, eggs, tea, with arrow-root, and animal food once 
a day. On the eighth day following the operation the parts 
were examined, and the stitches removed, when union was 
found to be complete. The patient was replaced in bed, and, 
after three days, the bowels opened, by administering one 
teaspoonful of ol. ricini every six hours. 

The next step was to restore the perineum. Four weeks 
were allowed to elapse, that the patient might recover from 
the confinement and effects of the first operation, after which 
the same preparatory measures were adopted as at the first. 
She was again etherized and placed in the usual position on 
the back, with the limbs fiexed on the body, and controlled 
by assistants. The vaginal surface of the vagino-rectal sep- 
tum was freshened for a little distance up, after which the 
knife was made to transfix the tissues on one side of the 
perineal rent, paring away a broad surface from below up- 
ward. The opposite side was subjected to a similar treat- 
ment, and as soon as the bleeding ceased, four long, curved 
needles, each bearing a silver thread, were deposited across 
the wound, the lower one first, and each made to enter and 
come out one inch from its margins, so as to include a large 
amount of tissue. These were secured as in the first opera- 
tion, and the subsequent treatment conducted in the same 
manner. The sutures were removed on the seventh day, the 
union being complete. 

Case II. — Mrs. , aged 23, from Pennsylvania, fell in 

labor with her first child. Last stage protracted, demand- 
ing the use of the forceps. The perineum gave way, the 
rent passing through the perineal centre, and severing the 
two segments of the sphincter ani and constrictor vaginae 
muscles. The accident entailed incontinence of the fasces, 
4 



42 LACERATION OF THE FEMALE PERINEUM. 

rendering her exceedingly miserable. Eight weeks after, I 
was invited by Dr. E. "Wilson to visit this lady and see what 
could be done in her case. An examination satisfied us as 
to the curability of the distressing accident. The following 
week the operation was performed. The patient, being 
brought under the influence of ether, was placed on her 
back before a good light, at the side of the bed, the hips 
resting on its edge, and the limbs flexed on the body and 
sustained, each, by assistant. The sides of the laceration 
were next pared by transfixing with a sharp-pointed bis- 
toury at their posterior extremities, and cutting forward, 
including to some extent the base of each labium ; the de- 
nuded surface being over one inch in breadth. The sides of 
the recto-vaginal septum were now carefully freshened for 
a little distance. The bleeding having ceased, two silver 
sutures w^ere first placed across the vagino-rectal chasm, and 
its sides brought together and secured by pellets of shot; 
this restored the septum. To effect the approximation and 
union of the sides of the perineum, four stout needles, two 
and a half inches long, and moderately curved, threaded 
with silver wire, were carried first through one side from 
without in, and then through the other from within out ; the 
one next the anus first, and all deeply inserted, entering and 
coming out one inch beyond the denued surfaces. The 
parts were now readily brought in contact by sliding the 
adjuster down over the wires while they were drawn upon, 
and then securing the retention by the shot-clamp, as 
previously described, cutting each suture off close to the 
leaden pellets. The patient was then placed in bed, an 
opiate administered consisting of opium one grain, a nutri- 
tious diet of animal broths directed, the urine removed from 
the bladder twice daily by the catheter, and the bowels kept 
closed by the exhibition of half a grain of opium morning 
and evening. On the seventh day following the operation, 
the stitches were removed, the union being well established. 
This lady has never complained of any inability to control 
perfectly the alvine discharges. She has likewise given birth 
to a child without any lesion of the cicatrix. 



REPORT OF OASES. 4-3 

Case III. — Mrs. Y., 39 years of age, residing a few miles 
from the city, married late in life. She became pregnant and 
fell in labor at full term. The structures of the perineum 
were rigid and unyielding, and the foetal head was for several 
hours engaged at the inferior strait, the delay not being doe 
to any malposition or disproportion between the head and 
pelvis, but from the obstinate resistance of the soft parts. 
Proper measures had been employed to overcome this source 
of difficulty by her physician, a very intelligent and com- 
petent gentleman ; and notwithstanding support was applied 
to the perineum, as the head emerged, a slit occurred, passing 
from the posterior commissure of the vulva into the anus, and 
extending in depth through the perineal centre, separating 
the muscles concentrating at this point. The accident in- 
volved incontinence of the faeces, unless stools were very con- 
sistent. Three months were allowed to elapse in order to give 
the parts time to recover completely from the injury, and 
the general health of the woman to be well established. At 
the expiration of this time I performed the operation for her 
cure, assisted by Drs. Read, H. Corson, and Townsend. The 
details of this case differed very little from those already 
described. The patient was etherized, placed on her back, 
and the hips brought down to the edge of the bed, the limbs 
being properly supported. A broad surface, three-fourths of 
an' inch in width, was pared away from either side of the 
fissure, and the recto-vaginal septum denuded for half an 
inch on the vaginal surface, by supporting it over the finger, 
introduced into the rectum while the knife was being care- 
full}' applied. Four silver threads were next deposited across 
the wound (observing to insert the lower one first), adjusted 
and clamped with shot, with intermediate ones of less depth, 
and the subsequent treatment, as to catheterism, opiates, and 
diet, conducted on the same plan as already indicated in 
previous cases. Seven days after, the sutures were all re- 
moved, and the union found complete. The patient was 
kept in bed for five days longer, the bowels being opened by 
the exhibition of small doses of castor oil, at intervals of five 



44 LACERATION OF THE FEMALE PERINEUM. 

or six hours. The function of the bowel was completely 
restored. 

Case IV. — M. A., an Irish woman, aged 24 years, was 
admitted into the Pennsylvania Hospital by Dr. Hunt. Her 
first labor, she stated, had been difficult and prolonged, al- 
though she had received no intimation of there being any- 
thing unusual in either the presentation or position. An 
intense pain expelled the head quite suddenly and unexpect- 
edly at last, the perineum being without support, and pro- 
duced a laceration, which extended through the sphincters 
into the bowel, entailing incontinence of the rectum. The 
mucous membrane of the intestine was considerably pro- 
lapsed, forming a red tumor at the outlet of the anus. 
Three months after the accident had elapsed, her health 
being good, the operation was performed by Dr. Hunt, as- 
sisted by Drs. Morton and Agnew, and in the presence of 
the resident physicians of the Institution. The edges, being 
well pared, were united by four silver threads, deeply in- 
serted and maintained securely in position by the shot- 
clamp, the intermediate ones being less deeply placed, and 
their ends twisted together. The treatment was similar to 
that adopted in the cases already detailed. All the sutures 
were removed by the eighth day, and the parts found accu- 
rately closed. This woman was discharged without any de- 
fect in the function of the bowel. 

Case V. — Mrs. , set. 25 years, during her second la- 
bor, which was tedious, though in no way complicated by an 
unusual position of the cephalic presentation, had the peri- 
neum torn, but not to such a degree as to render her incapa- 
ble of faecal control, except when the discharges were lacking 
in consistence. Two years after she gave birth to a third 
child, in which act the laceration was greatly extended, quite 
one inch up the bowel, and rendering her utterly powerless 
to restrain either flatus or alvine discharges. Imagining her 
case hopeless, and being exceedingly retiring and sensitive, 
she became greatly depressed, and for six years was obliged 



REPORT OF CASES. 45 

to live secluded from society. At the suggestion of a medi- 
cal relative, she was prevailed upon to allow me to examine 
her case, when an operation was agreed on. It is unneces- 
sary to repeat the formalities of the etherization, position, 
etc. The parts being properly exposed by the Sims specu- 
lum, the margins of the recto-vaginal fissure were freshened 
on the vaginal side, and afterward those of the perineum. 
Six silver threads were passed through the sides of the first, 
the upper one taking precedence, and the closure effected by 
the shot-clamp. Four sutures were next inserted through 
the sides of the perineal rent, and these brought in accurate 
contact by the adjuster and shot. The catheter was em- 
ployed morning and evening to relieve the bladder ; the 
bowels kept quiet by McMunn's elixir of opium, and a 
nutritious liquid diet directed, with a glass or two of wine 
daily. The sutures were all taken out by the seventh day, 
the parts having united well. This lady, not long since, was 
delivered of a child without any accident to the perineum. 

Case VI. — Mrs. ,aged 24 years, residing some distance 

from Philadelphia, fell in labor with her first child. There 
was nothing unusual in the position of the fcetal head, but 
its progress was very slow, and finally demanded the use of 
the forceps. While being adjusted, a violent pain came on 
with great suddenness, expelling head and instruments to- 
gether, dividing the perineum and involving the recto- 
vaginal septum. The child did not survive. She asserts 
with great positiveness the wound was inflicted by the blades 
of the forceps. 

The consequences entailed were unusually distressing, not 
only affecting the function of the bowel, but producing such 
displacement of the pelvic viscera as to disqualify her from 
taking exercise on foot, and affecting her general health and 
spirits. At the suggestion of Dr. Shultz, whose patient she 
afterwards became, I was consulted, and, after examination, 
advised an operation. This was subsequently performed in 
the usual manner, and the after-treatment skilfully conducted 
by the Doctor. The only thing worthy of note was the 



46 LACERATION OF THE FEMALE PERINEUM. 

giving way of the middle deep suture, and which most 
likely was due to some defect in the wire. This part, how- 
ever, healed up by granulation, being occasionally stimulated 
with the sulphate of copper, and although the progress was 
slow, yet the result was perfectly satisfactory, both in regard 
to the retentive power of the bowel and the capacity to take 
exercise. 

Case VII. — Mrs. , set. 23 years, in a first labor; head 

presentation, delivery by forceps; had the perineum lacerated, 
extending into the bowel. Dr. Hunt was called to see the 
case, by Dr. Reid, and, after examination, recommended an 
operation. The retentive function of the bowel was in a 
great measure destroyed, and her condition necessarily very 
uncomfortable. On the day of the operation I was invited 
by Dr. Hunt (by whose consent this case is reported) to aid 
him in its performance. After etherization the parts were 
extensively denuded and then brought together by four deep 
and three superficial interrupted sutures, the former secured 
with the shot-clamp and the latter by the twist. 

The after-treatment was judiciously conducted by Dr. Reid 
on the plan described in former cases. On the seventh day 
the sutures were removed and union* found complete. Four 
days after, the bowels were opened carefully, and at the ex- 
piration of eight days more the woman was sitting up. I 
have heard frequently since from this lady, and am assured 
her restoration is perfect. 

Case VIII. — Mrs. , set. 24, in a first labor, with a head 

presentation, delivered of a dead child with the forceps; re- 
ceived an extensive injury of the perineum. She does not 
think there was anything peculiar in the position of the pre- 
senting part, having heard nothing from her physician to 
that effect. The terminating stage of her labor, she states, 
was unusually long and severe, the head resting several hours 
on the distended perineum. The laceration passed through 
the perineal centre and three-quarters of an inch up the 
recto-vaginal septum. Her condition she believed to be irre- 



REPORT OF CASES. 47 

mediable. After the birth of a second child she passed into 
the care of my friend, Dr. Spooner, a skilful obstetrician, 
and at his suggestion, consented to an operation. At the 
date of its performance her child was four months old and 
nursing at the breast. She had no control whatever over the 
intestinal contents, and her situation was peculiarly dis- 
tressing. 

Aided by Drs. Spooner, Andrews, and Sherk, I executed 
my usual operation. The only event worthy of notice during 
the progress of the case was the accumulation of a large mass 
of hardened faeces in the lower bowel, which, on the ninth 
day, was expelled with great difficulty, remaining for some 
time in the anus, which was excessively distended, and tear- 
ing open the cicatrix for a little distance forward from the 
verge of the bowel. An experienced nurse could have pre- 
vented this occurrence by an early recognition of the trouble 
and the employment of injections. An examination, how- 
ever, revealed the fact that the separation extended simply 
into the fascia, while the deep portion remained uninjured. 
The chasm rapidly granulated up, and the cure proved suc- 
cessful beyond our expectations. 

Case IX. — Mrs. , aged 30, in a tedious labor, eighteen 

years ago, the particulars of which T am unable to learn, re- 
ceived a perineal rupture, extending to, but not through the 
muscular centre. While the ability to control the intestinal 
contents was not lost, yet the support to the pelvic viscera 
being diminished, it was followed by displacement of the 
uterus and a train of distressing nervous symptoms. The 
employment of mechanical appliances to correct the mal- 
position of the womb was frustrated from the want of a 
proper base of support. An operation to restore the peri- 
neum was suggested by her physician, Dr. Ellwood Wilson. 
The operation was shortly after executed, assisted by Drs. 
Wilson, J. Forsj'th Meigs, and W. Pepper, Jr. Nothing 
unusual took place in the subsequent conduct of the case, 
and the result proved a complete success. The effect on the 
general health of the patient justifies us in stating that ex- 



48 LACERATION OF THE FEMALE PERINEUM. 

ercise on foot could be taken with comparative comfort, 
although her nervous condition was not materially benefited. 
The time, however (three months), which has elapsed since 
the recovery, is . too short to determine what results may 
accrue. 

Case X. — E. M , aged 52 years, admitted into the 

Pennsylvania Hospital suffering from complete procidentia 
of the uterus. Fig. 12, from a sketch taken at the time by 
Dr. George Pepper, represents with great faithfulness the 

Fiff. 12. 




appearance presented at the period of the operation. She 
states that 20 years previous she had given birth to twins. 
The labor was tedious, but no instruments were used. She 
thinks it was at this time the perineum was torn. Five 
years after, she was delivered of another child, and the rent 
increased ; shortly after which the uterine displacement came 
on, becoming gradually worse, until almost disqualified for 
work, she sought medical advice. Believing that the resto- 
ration of the continuity of the perineum would offer an 
obstacle to the escape of the uterus, Dr. Hunt performed 
the operation, assisted by Drs. Morton and Agnew, and in 



REPORT OF CASES. 



49 



the presence of the Hospital residents. The patient being 
previously etherized and placed on the back, the limbs sup- 



Fig. 13. 




Fiff. 14. 




ported in the usual manner, the margins were extensively 
denuded, as shown in Fig. 13. Four deep silver sutures were 



50 LACERATION OF THE FEMALE PERINEUM. 

inserted and secured by clamps of shot, and intermediate to 
these, two superficial sutures, fastened by twisting the ends 
about each other. A .broad piece of adhesive plaster was 
next drawn across the nates to relieve the sutures of tension, 
and an elastic catheter placed in the bladder for a time. Fig. 
14 exhibits the operation completed. 

The drawings from which these cuts were taken were exe- 
cuted by the skilful pencil of Dr. George Pepper. 

On the fourth day the deep sutures were removed, and on 
the seventh the superficial ones, union being complete. A 
week later this woman was discharged from the Hospital 
perfectly well and free from all displacement. 

Case XI. — Mrs. B , a lady from the West, suffered 

from an extensive laceration of the perineum, involving the 
sphincter and recto-vaginal septum. The accident occurred 
in her first labor, which was tedious, though, I believe, not 
instrumental. There was considerable displacement of the 
pelvic viscera, in consequence of the absence of perineal sup- 
port. 

The operation described in the text was performed in the 
presence of Drs. E. "Wilson, Albert H. Smith, and others. 
After careful denudation of the sides and septum, four deep, 
interrupted wire sutures were deposited as directed in the 
text, and securely clamped. Seven days after, the stitches 
were removed and the union found complete. 

Case XII. — Mrs. , a resident of an adjoining county, 

in her first labor, ruptured the perineum, divided the sphinc- 
ter, the rent extending full three-quarters of an inch into the 
septum. The insufficiency of the bowel was most distress- 
ing. In the presence of Drs. E. W. Baily, Morrison, and 
Martin, I performed my usual operation. The lady was left 
in the care of Dr. Baily, who removed the sutures, (four in 
number) after the lapse of seven days, the union being com- 
plete. This lady has never complained of any difficulty with 
either the faeces or flatus since the restoration. 



REPORT OF CASES. 51 

Case XIIL — An Irish woman, at an adjoining town, in her 
first labor, before assistance could be obtained, ruptured the 
perineum. The septum was involved to such a degree as to 
entail incontinence, unless the faeces were quite consistent. 

Twelve weeks after the accident, with the assistance of 
Drs. Uhler, Goodell, Jenks, and Hunter, the parts were closed, 
with four deep, and two superficial, stitches, after the man- 
ner already laid down. Seven clays afterward I removed 
the sutures, and found the adhesion perfect, and since have 
learned of her entire recovery. 

Case XI Y. — Mrs. , of a neighboring town, after a long 

and tedious instrumental labor tore the perineum, the fissure 
extending so far into the septum as to lay both canals into 
one, for the extent of one inch. Two months after the occur- 
rence I closed the gap after the usual manner, assisted by Drs. 
Eeed, Beaver, and Hunter. As'I was securing the last and 
anterior wire, the posterior or first suture, from some defect, 
gave way. Unwilling to open the wound, the case was 
allowed to take its course, as the other sutures appeared to 
maintain the approximation. I said at the time, this will 
test the value of the first stitch, on which I have always 
placed so much importance. The usual time of seven days 
elapsed, and the sutures were removed ; union of the peri- 
neum had taken place, but not of the septum, leaving, of 
course, an opening between the rectum and vagina. After 
four weeks I repeated the operation, the restoration being 
complete. 

These last four cases are selected from a large number 
which I have treated since the first publicatien of my paper, 
merely because they were extreme cases, and which, at one 
time, and even at present by some surgeons, would have been 
subjected to two operations— one to close the septum, and a 
second to restore the perineum. In view, therefore, of my 
past experience and observation, the following points are 
conclusively settled in my mind. 



52 LACERATION OF THE FEMALE PERINEUM. 

First. — That laceration of the perineum and the recto- 
vaginal septum can be satisfactorily cured at a single opera- 
tion. 

Second. — That by the peculiar method of inserting the first 
suture there is no necessity for a series of stitches to close the 
septum independent of those used for the closure of the peri- 
neum. 

Third. — That the interrupted can be substituted for the 
quilled suture. 

Fourth. — That the division of the sphincter is not neces- 
sary to a cure. 

Fifth. — That the superficial sutures may be dispensed with. 



Literature of Lacerated Perineum. 

Midwifery, the Modern Practice of M. Lond., 1T73. 

Gehler, J. G. Progr.de ruptura perinseiin partu cavenda. Lips., 

1181-4. 
Denman, Th. Introduction to the Practice of Midwifeiy. Lond., 

1188. Chap, ii., sect, vii., pp. 69 and 70. 
Hagen, M. I. Diss, de praecavencla interfoeminei dilaceratione. 

Mogunt., 1790. 
Oken. Isis, Vergl. 1831. Heft 8-10, s. 925. 
Dieffenbach, I. F. Chir. Erfahrungen, besonders iiber die Wied- 

erherstellung zerstorter Theile des men sch lichen Korpers nach 

einer neuen Methode. Mit. 2. Abbild. Berl. 1829, 8. 
Moreau. Considerations sur les perforations du perinee et sur 

le passage de l'enfant a travers de cette partie. (Revue Medi- 

cale Francaise et Etrang. Paris, June, 1830.) 
Hohl. Die geburtshiilfliche Exploration. Halle, 1834. Bd. 11, 

s. 417. 
Bitsch. Theoretisch-praktische Guburtskunde. S. 357, Taf. xxix. 

Pig. 197-19. Berl. 1834. 
Oettingen. De Diss, de Perinrei Rupturis ej usque cura. Dorp., 

1835. 
Duparcque, T. Histoire complete des Ruptures et des Dechi- 

rures de l'Uterus, du Yagin, et du Perinee. Paris, 1836. 



LITERATURE OF LACERATED PERINEUM. 53 

Sehneemann. Schmidt's Jahrbiicher der gesammten ineund aus- 
landischen Medizin. 1885. No. v., s. 368. 

F. Duparcque's Yollstandige Geschichte der Durchlocherungen, 
Einrisse und Zerreissungen des Uterus, der Vagina, unci des 
Periniiums, u. s. w., in einem zehr erweiterten, die Leistungen 
aller wissenschaftlich gebildeten Nationen der ganzen Erde 
beriicksichtigenden Masse bearbeitet von J. F. W. Nevermann. 
Quedlinb. und Leipz., 1838. 

Busch. Die geburtshiilfliche Klinik an der Konigl. Friedrich 
Wilhelms — Universitatzu Berlin. Erster Bericht, Berlin, 1837 
S. 170, und s. 230. 

Noel. Journal General de Medecine. Tom. iv. ; Saucerotte, Idem, 
torn. vii. 

E. v. Siebold's Journal fur Geburtshiilfe. Schmitt, Bd. ii., s. 1 ; 

v. Siebold, Bd. v., i. s. 69. 
Wendelstddt. Hufeland's Journal der Praktischen Heilkunde. 

Bd. xv., st. ill., s. 85. 



The above authorities have been obtained from Busch 
and Moser, and I am greatly indebted to Messrs. Miiller and 
Mustin for aid in translations and searches of many of the 
works. 

Lancet, vol. i., 1849, p. 555. Joseph Rogers's case. 

Luncet, vol. ii., 1849. Dr. Barnes's case. 

Lancet, vol. ii., 1849, p. 661. H.gginbotham. 

Lancet, vol. ii., 1849, p. 672. Westminster Hospital. Mr. Holt. 

Lancet, vol. ii., 1850, p. 93. Mr. Fergusson. 

Guy's Hospital Beports, vol. viii., part ii., p. 401. 1850. Dr. 

Lever's paper on Lacerated Perineum. 
Guy's Hospital Beports, vol. xi., 1865. Cases detailed and method 

of treatment. 
Lancet, September 9, 1865. Lane's cases. 
Boston Med. and Surg. Journal, vol. x., page 405. Report of five 

operations of M. Roux, of Paris (1831-34). Extract from 

Journal Hebdomadaire. 



54 LACERATION OF THE FEMALE PERINEUM. 

Boston Med. and Surg. Journal, vol. ix. Operations of Dr. Joha 
P. Mettauer, of Virginia. 

Boston Bled, and Surg. Journal, vol. xxii., page 123. Case of 
Spontaneous Adhesion of Lacerations of Perineum, Occlusion 
of Vagina, and Operation for Relief, by Dr. Trowbridge Wil- 
loughby, University of Lake Erie, 1840. 

Boston Med. and Surg. Journal, vol. xxxi., page 319. Operation 
for cure of Lacerated Perineum, by Dr. W. B. Lindsay, Plaque- 
mine, La., May, 1848. (From N. 0. Med. Jour.) 

Boston Med. and Surg. Journal, vol. Ix., page 67. Union of La- 
cerated Perineum by position merely, by M. Nelaton, Paris, 
1856. (From Jour, de Medecine, &c, Bordeaux.) 

Boston Med. and Surg. Journal, vol. lv., page 517. Article on 
Treatment of Laceration of Perineum, by Prof. Schuh, of 
Vienna. (Wiener Med. Wochenschrift, 1857.) 

Boston Med. and Surg. Journal, vol. lvi., page 49. Laceration of 
the Perineum followed by Prolapse of Bladder and Rectum, 
Cured by Operation, by William Read, M.D. Boston Lying- 
in Hospital, December 13, 1857. 

Boston Med. and Surg. Journal, vol. lix., page 308. Operation for 
Restoration of Lacerated Perineum, by William M. Morland, 
M.D., Dec. 7, 1857. 

Boston Med. and Surg. Journal, vol. lxi., page 171. Case of Pe- 
rineal Laceration. Operation by . A Sacramento Calf. 

August 16, 1858. 

American Journal of Med. Sciences, vol. xi., 1822, page 525. Case 
of Laceration of Centre of Perineum. Operation. Remarks. 
Baron Dupuytren. 

American Journal of Med. Sciences, vol. xiii., 1833, page 113. A 
Case of Ununited Parturient Laceration of Recto-Vaginal Sep- 
tum, successfully treated with metallic ligatures, by John P. 
Mettauer, M.D., Prince Edward County, Virginia. 

American Journal of Med. Sciences, vol. xxiii. (1838-9), page 495. 
A report of nine cases of Lacerated Perineum, treated by Prof. 
Dieffenbach. (Berlin Med. Zeit., December 27, 1837.) 

American Journal of Med. Sciences, 1841, N. S., vol. i., page 99. 
Article on Laceration of Perineum during Labor (with opera- 



LITERATURE OF LACERATED PERINEUM. 55 

tions for cure), by Dr. William H. Fahnestoek, M.D., Borden- 
town, New Jersey. 

American Journal of Med. Sciences, 1844, N. S., vol. vii., page 472. 
Suture of Perineum performed immediately after Delivery, by 
M. Daujeau, Surg. Maternite a Paris. A report of six cases. 

American Journal of Med. Sciences, 1847, vol. xiii., page 314. A 
report of two operations, by John P. Mettauer, A.M., M.D., 
LL.D., Virginia. 

American Journal of Med. Sciences, 1853, vol. xxv. Discussion 
of a New Method of Operating for Lacerated Perineum, by I. B. 
Brown, M.D. 

American Journal of Med. Sciences, 1850, vol. xx., page 329. 
Hints on Treatment of Lacerated Perineum from Parturition, 
by W. E. Horner, M.D. 

American Journal of Med. Sciences, 1854, vol. xxviii., page 404. 
Operation for Laceration of Perineum, by T. M. Robertson, 
M.D. 

American Journal of Med. Sciences, 1855, vol. xxix., page 274. 
Laceration of Perineum and Sphincter Ani during Parturition, 
cured by Division of the Sphincter and subsequent closing of 
the Perineum by Sutures, by Willard Parker, M.D. (Oct. 24, 
1849). 

New Jersey Med. Reporter, 1856, vol. ix., page 466. Laceration of 
Perineum. Case successfully operated on by Dr. I. B. Brown's 
operation, by S. W. Butler, M.D., Burlington, New Jersey. 

Monthly Journal of Med. Sciences, February, 1854. Page 164. 
Proposal for the Effectual Cure of Prolapsus of the Pelvic Vis- 
cera and Lacerated Perineum. By John Hilton, Esq., F.R. S. 
(Guy's Hospital Reports.) 

Medical Times and Gazette, August 30, 1856. Page 215. Treat- 
ment of Ruptured Perineum. By Dr. N. Wilson Varina. 

British Med. Journal, August 17, 1861. Page 171. Rupture 
of the Perineum during Labor. By Dr. Thomas Skinner. 
Liverpool. 

Guy's Hospital Reports, 1865. Vol. ix. Page 270. On the Opera- 
tion for the Relief of a Lacerated Perineum and Sphincter Ani, 
&c, with some of its Complications. By Thomas Bryant, Esq., 
Assistant Surgeon to Guy's Hospital. 



56 LACERATION OF THE FEMALE PERINEUM. 

Lancet, September 9, 1865. Page 289. Two Cases of Operation 
for the Cure of Laceration of the Perineum, under the care of 
James Lane, Esq., at St. Mary's Hospital. 

Report of Columbia Hospital for Women, 1873, by J. Harry 
Thompson, M.D., Surgeon-in-Chief. Thirty-four Cases of Lace- 
rated Perineum treated. 



VESICOVAGINAL FISTULA 

ITS HISTORY AND TREATMENT. 



History. 



Theee is much consoling in the thought that, in most of 
the diseases and accidents incident to the body, the sufferers 
are not debarred the society, sympathy, and entertainment of 
friends. Such considerations greatly mitigate and sustain, 
under the severest physical distress. But there is one accident 
liable to occur in the female — and that, too, in the exercise 
of the highest function of her nature — which dooms her to 
isolation and seclusion, renders her presence intolerable to 
friends, and compels her to exist in an atmosphere repugnant 
in the highest degree to her own sense. 

Until a very recent period, the unfortunate victim of 
vesico-vaerinal fistula was obliged to confront her situation 
under the conviction that her case was absolutely hopeless, 
and has, in some instances, sought refuge from the mental 
suffering by self-destruction. One of the grandest triumphs 
of American surgery — for it is all her own — has been to step 
in and lead such forth into the light of day, and restore them 
to the bliss of family and social life. 

Antecedent to the discovery of the forceps, such accidents 
must have been of very frequent occurrence, although com- 
paratively little is said in medical or surgical works on the 
subject, as such were, by common consent, regarded to be 
beyond the resources of obstetric surgery. 

Hippocrates speaks of a discharge of urine through the 
vagina sometimes following difficult labors, with some un- 
important remarks in regard to cleanliness ; no hint is any- 
5 



58 VESICO- VAGINAL FISTULA. 

where thrown out, leading to an inference that such cases 
admitted of cure. "Without disturbing the repose of ancient 
medical record, it may not prove uninteresting to interrogate 
a few modern authorities. 

Mauriceau, in his work, published in 1712, lays down the 
following aphorism: " L'issue involuntaire de Purine cansee 
par line fistule qui s'est femme, est ordinairement incurable 
si elle duze plus si trois mois." No operation does he pro- 
pose, but only looks for a cure, when it does occur, as a purely 
natural or spontaneous result. 

Hoffman, in 1724, describes the accident, and refers it to 
the proper cause : " Quando enim fibres sub diuturnoribus 
partus laboribus ad infantis capiti, ad os pubis compressa? diu 
manet fieri deinde solet ut inflamentur, atque in abscessum 
abeant, aliquot denum a partu diebus consummandum ; unde 
fluxus, et stillicidium uringe per vaginam tertio demum, vel 
quarto die contingit." It is quite evident, too, the art of the 
Genevan embraced no means of repairing the accident. 

Astruc, physician to the King of France in 1776, has no 
notice whatever of the affection in his work. 

Smellie, in his publication of 1776, although he describes 
an operation for this form of fistula, had evidently never 
performed one himself or even witnessed it performed, as he 
adds, " I wish the operation may not be found impracticable." 

Denman alludes to ulceration and sloughing of the vagina 
after difficult labor, but suggests no remedy. 

Burns, in his work on midwifery, edited in 1820 by James, 
describes the lesion, and advises a catheter to be worn for 
some time, under the conviction nothing else could be done. 

Conquest, in his Outlines of Midwifery, published in London 
in 1820, insists on the propriety of attempting a cure by an 
operation, but does not designate any particular method, nor 
does he intimate a knowledge of any cures having been 
effected. 

James, in his System of Midwifery, of 1813, not only takes 
notice of this form of fistula, but advises the employment of 
an elastic catheter, and adds, perhcqis it may heal. The same 
author also speaks of the use of caustic when the opening is 



HISTORY. 59 

small, and freshening the edges when it is large, conjoined 
with the use of the catheter. 

Ashwell, quite a prominent practitioner and writer in 
London, in 1828, has no allusion to the subject whatever 1 . 

William Campbell, of Edinburgh, in 1833, appears to have 
given unusual attention to the subject. The opening is 
clearly described, and its most common location, near the 
neck -of the bladder. In his experience, the catheter and re- 
cumbent position perseveringly employed has, when pro- 
nounced by others utterly hopeless, permanently relieved cases: 
the phraseology, it will be perceived, will not allow the con- 
elusion that such were cured. 

G-ooch, in 1831, alludes to a case having got well by a 
gum-elastic bottle, with a sponge attached, being pressed 
into the vagina and kept opposite the opening. This solitary 
case of reported cure is treated as a very unusual and extra- 
ordinary event. 

The cases reported as cured by Lallemande, Phillips of 
Eheims, and Vidal, in 1834, Yelpeau most positively asserts 
were not cures. 

Blundell, in his work published in 1834, disposes of the 
subject in a most summary manner by stating, "a slough of 
the vagina may lay open the bladder." 

Ramsbotham, writing as late as 1841, does not treat of the 
subject. 

Davis, in 1841, describes the manner in which such an 
opening is made, with the additional statement, " it is almost 
a universal fact, that they never do heal." 

Dewees, in his work on midwifery, makes no mention of 
it. 

Churchill, in 1844, speaks of all such openings as being 
perfectly hopeless. 

Simpson, in his work published in 1865 and 1866, when 
describing the result of long-continued pressure by the foetal 
head against the vesico-vaginal septum, speaks of the slough 
separating and leaving an incurable fistula. 

Reybard, in 1856, published a paper on the palliative 



60 VESICO- VAGINAL FISTULA. 

treatment of this form of fistula, believing the affection in- 
capable of cure. 

Let us now interrogate a few of the eminent surgeons 
abroad and at home, and ascertain with what voice they tes- 
tify on this subject. 

Ambrose Parens great work bears date 1582, and while the 
subject of fistula in general is discussed, this form is not even 
mentioned. 

Heister mentions it as incurable. 

Samuel Cooper, in his Surgical Dictionary, speaks of differ- 
ent kinds of fistula, but does not in any way allude to the 
one under consideration. In 1808, in the first volume of his 
Surgery, some methods of operation for the cure of such 
fistulse are described, but he evidently doubts their practica- 
bility. 

Mr. Liston asserts that an operation only makes the patient 
worse, by converting a small into a large opening, and adds, 
" There is little hope in a case of any size." To the same 
conclusion tend the testimony of Mr. Earle and Mr. Law- 
rence, both of whom state a successful operation impracti- 
cable. 

Chelius says the prognosis is always very unfavorable. 

Miller believes a favorable result by any means improbable. 

Yelpeau asserts of all cases reported as cured, there were 
few free from doubt. 

Pirrie has not a word upon the subject. The subject is not 
introduced by name into the works of Dorsey or Gibson. 

Desault, in his Treatise on the Urinary Organs, confines 
himself simply to the palliative treatment. 

Dupuytren only hoped, by cauterization, to effect something. 

Mr. Earle, after thirty operations, succeeded in curing one 
case ; no wonder he pronounced the operation the most diffi- 
cult or unsatisfactory one in surgery. 

Nelaton, as late as 1854, talked of autoplastic processes 
and the cautery. These are but a few of the names which 
might be introduced. 

In 1839, Dr. Hayward, of Boston, succeeded in curing a 
case by freshening the edges, and approximating them with 



CAUSES. 61 

a thread suture. In 1840, two additional cases were treated, 
with a similar result, and although twenty operations were 
performed in attaining these three cures, yet, in a prospective 
point of view, their value cannot be overestimated. 

In 1847, Dr. Pancoast, Professor of Anatomy in the Jeffer- 
son Medical College, reported two cases, cured by a tongue, 
and grooved incision, the wound being adjusted by his silk- 
thread plastic suture. In the same year, Dr. Mettauer, of 
Virginia, gave to the profession the history of a case success- 
fully treated by vivifying the edges, and uniting the same 
with leaden threads. Such occasional cures, doubtless, tended 
to inspire a hope of the ultimate curability of this disgust- 
ing disease ; but it was not, however, until about 1852, when 
Dr. I. Marion Sims, then of Montgomery, Alabama, gave to 
the profession the fruit of his labor and observation, by which 
this operation was removed from the category of probabilities, 
and crowned with a success which compared favorably with 
any of the established operations in surgery. For this he 
has placed the civilized world under a debt of gratitude. 

Causes. 

Among the causes inducing this lesion may be enumerated : 
First. The pessary. — When this instrument is out of pro- 
portion, and fitting badly, or corroded, or encrusted with 
saline matters, it may induce ulceration of the vagino-vesical 
septum. Profs. Beirards and Lisfranc each relate a case of 
the bladder and rectum both being opened by a pessary ; one 
of the patients died of peritonitis (Journ. Nouv. Hebd. de Med., 
t. 1, page 263.) A case of Dupuytren, in the Hotel Dieu, is 
recorded in the Diet, de Sciences Med., t. vii.p. 47, of a young 
country woman, whose rectum, vagina, and bladder freely 
communicated, in consequence of wearing a badly adapted 
instrument ; both of these were produced by stem pessaries. 
A case of this kind is also cited by Desormeaux, a French 
physician. In most of them, doubtless, the ulceration was 
brought about by saline deposit on the exterior of the instru- 
ment, the angularities of which matter would very soon pro- 
duce destruction of tissue. Other cases might be introduced 



62 VESICO- VAGINAL FISTULA. 

in illustration of the same point. In earlier times it is pro- 
bable such accidents were common, when a great variety of 
extraordinary materials were employed, not only for mechani- 
cal support, but as means of introducing remedial agents into 
the organs of generation ; at present, improvements in the 
form and substance of mechanical supports will not be likely 
to furnish us a case illustrative of the condition under con- 
sideration. 

Second. Foreign substances in the bladder. — Under this head 
may be mentioned vesical-calculi, examples of which are by 
no means rare. Fabricius Hildanus relates an instance of 
this nature. Sir Benjamin Brodie another, in which the 
stone made its way into the vagina by ulceration; and a 
third is given by Sir Astley Cooper. Dr. Dunlap, of Morris- 
town, in this State, exhibited to me a calculus as large as a 
hen's egg, which he extracted from the vagina of a female, 
who had long suffered from the disease, and which had per- 
forated the vesico-vaginal septum. A most interesting fact 
connected with this case, was the perfect restoration of the 
parts subsequently by granulation. A very singular case 
occurred in the East London Lying-in Institute, reported in 
the January number of the French Lancet for 1838, of a 
woman who, in consequence of a chronic retention of urine, 
had acquired sufficient dexterity to catheterize herself. From 
some cause, being without the usual instrument, she extem- 
porized the catheter with the stem of a clay tobacco pipe. 
On one occasion it was broken, a portion remaining in the 
bladder, and which, in time, not only passed into the vagina, 
but finally into the uterus, from which it was extracted. 

Thied. Carcinomatous and other forms of ulceration. — Almost 
every work treating of the diseases of the female genitalia, fur- 
nishes examples of malignant growths, involving the uterus, 
and gradually invading, by destructive ulceration, the vagina 
and rectum, until they become converted into a common 
cavity. Phagedenic chancre may produce a similar result. 
Two cases of this nature came under my own observation in 
the wards of the Philadelphia Hospital, rendering the poor, 



CAUSES. 63 

unfortunate outcasts, objects of the profoundest commisera- 
tion. 

Fourth. Wounds of the vagino-vesical wall in the legitimate 
and illegitimate use of instruments. — Under the first may be 
enumerated the careless employment of the obstetrical vectis 
or lever, bruising or lacerating the tissues by long-continued 
efforts to modify a foetal position, or the slipping of a perfo- 
rator in cases of craniotomy. The forceps have come in for a 
large share of animadversion, but they have little agency in 
producing such an accident; their earlier and more frequent 
employment, particularly in educated hands, would have pre- 
vented many which have occurred. Under the second head 
may be adduced the violence committed by those ignorant 
scoundrels who flourish in every great city in their criminal 
attempts to procure abortion. 

Fifth. Pressure of the foetal head. — This, above all others, 
is the most common cause of vesicovaginal fistula. It is 
probably not going too far to say 90 per cent, of such occur- 
rences are due to the prolonged pressure of the foetal head. 
The testimony of almost all authors harmonizes in this par- 
ticular. It was so regarded by Mauriceau ; yet singularly 
enough, he was greatly opposed to the use of instruments, 
whereby a tedious labor might be brought to a close. This 
prejudice it is said was due to the failure of Chamberlayne 
to deliver a woman in Paris after a public boast. Not being 
aware of the existence of a deformed pelvis he had torn the 
vagina and uterus in several places in his ineffectual efforts 
to extract the child with the forceps of which he was the 
inventor. Denman attributed the lesion to long-continued 
compression of the soft parts. Davis expressly declares that 
it does not result from the use of instruments, but delayed 
labor. Dr. Simpson stops to fortify a similar opinion by 
stating "these abnormal openings, if produced by instru- 
ments, should appear at once, while it is known they only 
occur several days after their use." Smellie, Colombat, and 
Churchill, all ascribe the fistula to protracted pressure dur- 
ing labor, and an opinion of similar import is entertained by 
Professors Hodge and Meigs. Doctors Sims and Boseman, 



64 YESICO- VAGINAL FISTULA. 

whose opportunities for acquiring accurate information on 
this subject have been extensive, testify to the same fact, and 
except in a single case my own observation accords with these 
gentlemen. 

If the foregoing statements be correct, what is the modus 
— the manner in which the lesion takes place ? The head in 
passing through the pelvic cavity presses the anterior wall 
of the vagina toward and against the posterior face of the 
pubic bones. If in consequence of failure of the uterine ex- 
pulsive efforts, or a disproportion between the pelvis and the 
head, or a want of accord between the diameters of the two, 
the head long remains thus engaged, the vitality of the soft 
parts so compressed and bruised will be destroyed, either by 
the formation of a slough or by inflammation and ulceration. 
It is asserted by some that a fold of the vagina is caught and 
pressed against the pelvic bones until its death is insured ; 
but it does not seem probable any such folds would exist 
when the canal is so greatly distended. The period when the 
opening occurs varies in different cases ; in some as early as 
the fourth or fifth day, and in others the event may be pro- 
longed — as in one which came under my own observation 
(case 4) — until the twenty-first day after confinement. \Then 
the parts are so injured as to induce ulcerative inflammation, 
a longer time is required to penetrate the vagino-vesical wall 
than where they are killed outright, and drop out as a 
slough. 

Classification. 

These fistulse may occur at any point from the middle of 
the urethra to the termination above of the anterior wall of 
the vagina, but practically the classification of Sims or that 
of Dr. Boseman, the two differing very little, answers every 
purpose. 

First. TJrethro-vaginal ; the opening being between the 
urethra and vagina. 

Second. In the trigone vesicate ; the opening being situated 
at the cervix of the bladder. 



FORM, SIZE, AND CONDITION. 65 

Third. At the bas-fond ; the opening involving the inferior 
fundus of the bladder. 

Fourth. Vesico-ntero-vaginal ; where the opening commu- 
nicates with the bladder, vagina, and cervix, or body of the 
uterus. 

Fifth. Fortunately quite rare, where the entire vesico- 
vaginal wall is destroyed, and it may be the urethro-vaginal 
also. 

The relative frequency of these varieties, as they have come 
under my own notice, is as follows : First, at the vesical tri- 
angle ; second, at the bas-fond ; third, in the urethro-vaginal 
septum ; fourth, the utero-vesical ; and last, the one attended 
with a destruction which includes the first four classes. This, 
I think, accords with the experience of most observers. Dr. 
Boseman, I believe, states, according to his observation, the 
vesico-utero-vaginal is the most common. I have never but 
in a single instance seen an example of this kind. 

Direction. 

These fistules may be transverse, oblique, or longitudinal ; 
determined, it may be presumed, in a great degree by the 
particular part of the fcetal head impinging, or the exact 
manner in which the vaginal parietes may be caught. The 
transverse variety has most frequently come under my own 
notice. 

Form, Size, and Condition. 

The configuration or form of such openings may be oval, 
round, linear, angular, and elliptical; the last most common. 
A careful study of the muscular component of the vagina 
will explain this. Its fasciculi are disposed longitudinally 
and circular ; the former the most numerous and distinct ; 
and of these, those on the lateral parietes are so associated 
with the levatores ani that they contract less when divided 
than those occupying an intermediate position, and hence the 
ovoidal or elliptical form of most fistula. The dimensions of 
the opening also vary from an aperture so small as barely to 
admit the introduction of an ordinary probe, to one through 



66 VESICO- VAGINAL FISTULA. 

which might be passed a good-sized egg. So far as the 
patient's comfort is concerned, the small opening is quite as 
bad as the large one ; in either case the urine will be con- 
stantly passing the vagina. 

The condition of the borders of the fistula — like its size 
and form — differ much. Sometimes they are, especially the 
upper one, thin, inverted, quite pale and smooth ; in other 
instances thick, soft, spongy, and vascular; and again of 
almost cartilaginous consistence, inextensible and sparsely 
supplied with bloodvessels. The mucous membrane of the 
bladder often projects through the opening, forming a red, 
erectile-looking tumor. Dr. Gross gives a remarkable case — 
in his work on the urinary organs — of the entire bladder 
escaping through such a fistulous orifice into the vagina. 
The condition of the edges as to thickness, density, and 
vascularity, is a matter of great practical moment in the 
cure of disease. 

Diagnosis. 

It is not usually a difficult matter to ascertain the existence 
of this affection. If inquiry be made as to the state of the 
bladder immediately succeeding the labor, the patient or her 
attendant will state that for two or three days there was an 
inability to evacuate its contents, with some pain or uneasi- 
ness, requiring perhaps the use of the catheter ; after this a 
stilliciclium of urine through the urethra ; or this last con- 
dition may have been present from the first. At some period, 
however, varying from five to twenty days from the labor, 
the incontinence is complete, the urine escaping entirely from 
the vagina. The patient sometimes describes this state as 
being preceded by a sense of something giving way. The 
labia, inner surface of the thighs, perineum, and the buttocks, 
being constantly bathed in the secretion, become red, inflamed, 
and covered with a crop of pustules, which sometimes form 
ulcers of considerable depth.' The genitalia and surface of 
the vagina frequently become incrusted with a saline deposi- 
tion (urates), and a strong urinous odor is emitted from her 



COMPLICATIONS. 67 

person and clothing. These may be regarded as the rational 
signs of the disease. Although they do not in themselves 
establish or justify the conclusion that a fistula exists, they 
form a strong presumptive proof of the fact. Only upon a 
physical exploration of the parts can we ascertain with cer- 
tainty the accident. "With this view let the patient be placed 
in bed, on her side, with the limbs well drawn up, and the 
hips on the edge of the same, before the window, with a good 
light. Introduce the duck-bill speculum into the vagina, 
and draw the perineum well back toward the sacrum, until 
the entrance of the air distends the vaginal cavity. Tf the 
lesion exists, it will most likely be at once detected, unless it 
should be so small as to escape observation. That it be not 
thus overlooked, a pocket-case probe should be introduced 
into any suspicious pockets or depressions, and moved care- 
fully about until their nature and extent are determined. 
"Where the aperture is so small as not to be readily found, it 
has been advised to inject through the urethra into the blad- 
der some colored liquid, distending its walls, and carefully 
noting if any can be discovered passing into the vagina. 1 
Some prefer having the patient on her elbows and knees, 
others on the back, in making the examination, but the one 
on the side answers every end, and is more in consonance 
with her feelings of modesty and propriety. With the aid 
of the speculum no doubt need exist ; without it no exami- 
nation is complete. I have been called to cases said to be 
vagino-vesical fistulge, which on ocular inspection proved to 
be incontinence from defect in the muscular endowments of 
the vesical cervix, allowing the urine to find its way back 
into the vagina after escaping passively from the urethra. 

Complications. 

Under this head may be enumerated stricture of the va- 
gina, recto-vaginal fistula, obliteration of the urethra, and 
malignant disease of the uterus or rectum. 

1 Milk answers well for this purpose. 



68 VESICO- VAGINAL FISTULA. 



Treatment. 



The treatment of vesico- vaginal fistula includes the prepa- 
ration of the patient, the operation, and subsequent manage- 
ment. 

Preparation. — £To woman can be in the best condition to 
undergo an operation for her cure, until after the lapse of at least 
eight or ten weeks from her confinement. I have operated as 
early as the fifth week, and with complete success, but, never- 
theless, do not think so early a date should be fixed as a rule 
in practice. It requires at least two months before the system 
has completely recovered from the perturbating influences of 
the parturient act, and her secretions duly established. The 
moral and physical suffering induced by the existence of the 
fistula tend to put the woman out of health. If we find her 
pale, feeble, with loss of appetite, and harassed by a train of 
nervous symptoms, it may require several months of prepara- 
tion; during which time a carefully regulated nutritious 
diet will be demanded, fresh air, attention to the intestinal 
and other secretions, conjoined with the use of tonics, such 
as the preparations of iron or infusions of the bitter vege- 
table class. It is certain, no one familiar with the treatment 
of this form of fistula, will be rash enough to subject his 
patient to the inconvenience of such an operation, before 
attending to these preliminary measures. 

There is no operation in surgery which depends so much 
for its success on healthy constitutional conditions as the one 
under consideration, nor must we overlook the local treat- 
ment. All inflammation must have subsided, the connective 
tissue component of the parts must be well matured, and 
sufficiently dense to withstand the traction of the sutures, 
the edges of the opening should have considerable thickness 
and a good supply of bloodvessels. All this will be favored 
by due attention to cleanliness, injecting tepid or cold water, 
with the addition of a little palm soap, or a decoction of oak 
bark into the vagina every day. Should the edges continue 
pale and thin, they must be subjected to a special treatment, 
with a view to make them more voluminous. This is best 






TREATMENT. 69 

accomplished by making a few shallow incisions parallel to 
their long diameters, and rubbing into each a little nitrate of 
silver. The caustic should be used about every third day. 
In the course of a few weeks the requisite change will have 
taken place. The saline matters, which so commonly incrust 
the margins of the fistula and other parts of the genitalia, 
producing much uneasiness, may be counteracted by the in- 
ternal administration of nitro-muriatic acid, as a good tonic. 
The excoriation due to the urinous stillicidium is best relieved 
either by an ointment of the oxide of zinc, or by a mixture 
of the black wash and glycerine. Attention must also be 
given to her catamenial period, three or four days after its 
accomplishment being the most fitting time for the operation. 
If done during the latter half of the month, the irritation of 
the parts, together with the prolonged etherization, are prone 
to produce premature menstruation. The day previous to the 
operation, a gentle cathartic should be administered, after the 
action of which, one grain and a half of opium, in pill, should 
be given to quiet all intestinal irritation. 

Should the fistule be the result of carcinomatous ulcera- 
tion, any operation will be futile, as everything tends to a 
fatal termination. "When it coexists with a recto-vaginal 
opening, the escape of purulent matter into the vagina will 
be unfavorable to healing ; yet, if the peristaltic movements 
can be sufficiently controlled by opium or some of its prepa- 
rations, there is no reason why the vagino-vesical fistula 
should not be closed, before undertaking that between the 
vagina and intestine. 

The complication most commonly met with is stricture of 
the vagina, and, as the opening is usually above it, nothing 
can be done for its relief until the dimensions of the canal 
are properly restored. Three methods may be employed for 
this purpose. First. Incisions of the stricture through the 
mucous and submucous tissues, followed by dilatation. 
Second. A submucous division of the contracted bands, and 
subsequent dilatation ; and third. Dilatation alone. Choose 
which we may, there is a strong tendency in the stricture to 
return. If incision be selected, the reformed parts have the 



70 VESICO- VAGINAL FISTULA. 

same vicious tendency to contract, and although this is true 
of dilatation, it is less so than either of the others, and should 
be selected as best adapted for our purpose. It is effected by 
either graduated bougies or sponge-tents. I have practised 
each method, and am confident the last is the most certain 
and least painful. 

Treatment. 

This is divided into the palliative and radical. If, in con- 
sequence of extensive destruction of tissue, or the presence 
of malignant disease, an operation is contra-indicated, we 
may resort to some means to palliate the distressing situation 
of the patient. These chiefly point to the collection of the 
urine so as to defend her person against excoriation and 
offensive emanations. There is no task so difficult and un- 
satisfactory as this. Many receptacles, and obturators, and 
other contrivances have been devised ; such as a bag of gum- 
elastic worn partly within and partly without the vagina, 
styled by Colombat the " trou d'enfer" of Feburier ; or a 
gum bottle with a sponge on its anterior face, introduced 
into the canal ; or tampons of fine linen, or soft sponge 
so adjusted as to occlude the opening. Of all these 
devices the metallic shield of Prof. Meigs answers the best 
purpose, yet it must be confessed all are but sorry contri- 
vances, and will be soon abandoned. A rigid attention to 
cleanliness, by frequent ablution, and the use of an inter- 
femoral napkin or diaper, will, perhaps, give most satisfaction. 
Fabricius Hildanus, as related by Colombat, furnishes an in- 
stance of a case which was cured, after eight months, by 
vaginal injections, consisting of barley-water and the mucil- 
age of quince seeds. The following passage, in his quaint 
style, narrates the event: "Ilia autem continuo usa medica- 
mentis (ut dixi) conglutinantibus, et per intervalla etiam 
purgantibus, intra menses octo, non sine admiratione omnium 
eorum quibus res cognita plane curata fuit, adeo nunc Dei 
optimi maxima gratia ne guttula quidem urinse involuntarise 
affluat, sed a vesica colligatur, retineatur et excernatur non 
aliter ac si an tea, nunquam male affecta fuisset." 



TREATMENT. 71 

Radical treatment. — It was only about the beginning of the 
present century any attempts for the cure of this distressing 
malady were thought of, and only within the last twenty 
years that auy encouraging results have been attained. At 
present we approach the management of a case of vesico- 
vaginal fistula with the same degree of confidence as that of 
stone or hydrocele. The history of the various methods 
practised for its cure — although most of them have passed 
into history — will be presented, as they furnish the most re- 
markable example of untiring, undismayed perseverance in 
the face of the most unpromising results, and of a fertility of 
professional resourse to be found in no other department of 
medicine. These methods may be arranged under the follow- 
ing heads: — 

1st. By the catheter. 

2d. By the catheter, conjoined with the tampon. 

3d. By cauterization. 

4th. By the uniting apparatus. 

5th. By galvanism. 

6th. By transplantation. 

7th. By the suture. 

First. By the Catheter. — It is important to ascertain, at the 
earliest moment, the existence of a fistula, as a little well- 
timed attention may procure a cure without an operation. 
There are cases in which there exists a strong tendency to 
spontaneous cure, and advantage should be taken of this, and 
a catheter placed at once in the bladder, and worn for three 
or four weeks, the patient being confined to the recumbent 
position, and due attention to cleanliness observed^. A number 
of such cases terminating successfully have been placed on 
record, by Fabricius Hildanus, Blundell, Ryan, Sedillot, 
Campbell, of Edinburgh, Nelaton, and others ; and, I doubt 
not, similar ones may be recalled by many practitioners ex- 
tensively engaged in obstetric medicine. 

Second. Catheter conjoined with the Tampon. — This is usually 
described as the method of Desault, although it more pro- 
perly belongs to Boyer — the name of the former having 
doubtless become connected with it in consequence of the 



72 VESICO- VAGINAL FISTULA. 

truss-like apparatus which he devised to sustain and retain 
the catheter. 

A large-sized elastic catheter is introduced into the bladder, 
and its end slipped through an opening in a curved rod, one 
end of which is to be opposite the urinary meatus, and the 
other secured to an oval plate which rests on the pubes, and 
is in turn securely attached to a truss-spring surrounding the 
pelvis. This controls the catheter, by which means the urine 
is removed as rapidly as deposited. The margins of the 
fistula were next pressed towards each other by a round 
tampon or plug, made of fine linen filled with lint, well 
oiled, and pressed into the vagina. It does not appear, of the 
many cases thus treated by Boyer, more than a single one 
recovered. With a very slight modification of the vaginal 
plug, others — as Baines, Guthrie, Young, and Barnes — have 
reported cures, the treatment continuing from six to twelve 
months. Those curious to peruse these cases will find most 
of them in the Med.-Chir. Trans., vol. vi., page 582, and the 
Edinburgh Med. and Surg. Journal, April No., 1824. Colombat 
speaks favorably of this plan, provided the edges be first 
cauterized. It is probable any such cases reported as cured, 
recovered, not from the tampon, but from the persevering 
use of the catheter. The tampon could exert no influence 
whatever in pressing together the sides of the fistula, but 
just the reverse, by unfolding the rugse or plications of the 
canal by distension. Let any one notice how a fistula gaps 
when the speculum is introduced, and the canal distended 
with air, and then, in withdrawing, how the sides collapse, 
and the demonstration will be clear. 

Third. Cauterization. — Of this Colombat said : " It is the 
best method we can oppose to vesico-vaginal fistula." The 
agents employed were either the nitrate of silver or the 
actual cautery. The former was conveyed to the fistula by 
fixing a stick in a porte-crayon, and conducting it to the 
opening through a fenestrated speculum introduced into the 
vagina, and repeated every four or five days, followed by 
emollient injections to relieve pain. After the edges begin 
to assume a swollen or raw appearance, a catheter, according 



TREATMENT. 73 

to Colombat, should be placed in the bladder. A few suc- 
cessful cases by this mode of treatment have been reported by 
Dupuytren, Delpeeh, McDowell, of Kentucky, Liston, Colles, 
and Ferrall. When the cautery was used, a bean-shaped 
stylet, heated to a white heat, was applied to the opening, a 
fenestrum shielding the vagina being first introduced — and 
the parts lightly touched so as to induce a superficial slough. 
The advocates for caustics have been Chelius, Yacca, Ber- 
linghien, Czeekiersky, Ehrman, Monteggia, Guthrie, and 
Colombat; for the hot iron, Dupuytren, Delpeeh, Bellini, 
McDowell, Liston, Blasius, and DieiFenbach. The caustic 
treatment was somewhat modified by Lallemand, principally, 
who conjoined with it a uniting apparatus. This surgeon 
was so particular as to take an accurate cast of the fistula 
with a very plastic wax. After the edges were made suffi- 
ciently alive by the caustic, he adjusted his instrument, one 
portion of which acted as catheter, and through its openings 
hooks were made to protrude, penetrating the posterior lip 
of the fistula on its vesical surface. A roll of lint, or charpie, 
was next placed against the under surface of the urethra, and 
pressed upward toward the vagina by a movable plate con- 
nected to the anterior extremity of the catheter, the object 
being to press the lower lip of the fistula toward the other 
or upper lip impaled by the hooks. Dupuytren attempted the 
same thing by a peculiarly constructed catheter. Langen- 
beck very properly pronounces such devices as complicated, 
and devoid of practical value. 

Fourth. The Uniting Method. — Laugier, in order to bring 
the edges together, invented a pair of claw-forceps, the blades 
of which could be introduced separately, and after being 
implanted on opposite sides of the fistula, secured together, 
by which the coaptation was effected. Quite recently, an 
instrument, acting on the same principle, has been invented 
by Dr. Betancourt, while pursuing his studies in the Uni- 
versity of Pennsylvania (Fig. 15). 

These processes, unlike the others, act on the vaginal sur- 
face of the opening. As to their value, it may be said of all 
(5 



74 



VESICOVAGINAL FISTULA. 



of them, what Langenbeck pronounced of Lallemand's mode, 
" they are theoretical, and devoid of practical value." 

Lallemand, as far as I can ascertain, never reported more 
than a single case of cure, and even this Yelpeau declares 
proved a failure. Laugier confesses he had not succeeded in 
a single instance with his uniting forceps. 



15. 




Fig. 15 is two light metallic plates corrected by a hinge ; their margins are scal- 
loped, and support sharp hooks, designed to seize the margins of the fistula In one 
plate are two eyes, and in the other two movable posts with shoulders, which are in- 
tended to pass through the eyes and hold the plates together. 



Fifth. Galvanism. — The attempt to cure this malady by 
galvanism is due to Mr. Marshall, of the University College, 
London. The impression was to be made by bringing the 
poles of a battery in contact with the sides of the opening, 
and was only another phase of the cautery. It only serves 
to demonstrate the straits into which men are thrown when 
they resort to such chimerical expedients. 

Sixth. Transplantation. — A very ingenious operation was 
devised and executed by Jobert ; it was by transplantation 
of tissue. The circumference of the fistula, being drawn 
down, was freshened, a flap was raised from the inner surface 
of the labium, and, being turned into the opening, was secured 
by a number of stitches ; a catheter was kept constantly in 
the bladder during the treatment. In one case the growth 
of hair, the follicles of which were in the flap, induced a 
vaginitis, and also interfered with the execution of the con- 



TREATMENT. To 

jugal act. In one case the material to form this fleshy obtu- 
rator was taken from the buttock and thigh, and proved 
altogether successful in effecting a permanent cure. The 
results of four cases reported, furnish us with one cure, 
two failures, and one death. Where a large part of the 
vesicovaginal septum has been destroyed, the operation of 
Jobert might answer a valuable purpose. 

Seventh. By Suture. — The introduction of the suture marks 
an important epoch in the history of vaginal fistulse. It was 
a step in the right direction. The credit of its introduction 
is due to Roonhuysen, a distinguished obstetrician at Am- 
sterdam, who proposed its use in 1663. It was violently 
opposed long after by the celebrated Petit, who asserted that 
incising and introducing a thread in parts so situated was a 
task almost incapable of execution. 

The operation of Roonhuysen consisted in freshening the 
edges by means of a knife, scissors, or cutting forceps, ope- 
rating through a speculum, then pushing across the opening 
needles, formed from the quill of the swan, and binding the 
parts together by winding about these novel pins thread as we 
apply the twisted suture. Lewrinski, long after, in 1802, pro- 
posed the interrupted suture. It formed the subject of a thesis 
before the Faculty of Medicine in Paris. His instrument for 
placing the ligature was a catheter, carrying a needle which 
had a spring attached, and bearing a thread. This instru- 
ment was passed into the bladder, the spring pushed forward, 
making the needle to pierce the posterior wall, afterward the 
anterior wall, and securing by a serre-noeud. 

Volter recommended after paring the edges to coaptate by 
the interrupted suture. To execute this he used curved 
needles, threaded with waxed silk, and passed them at short 
intervals through the margins of the fistula, securing each 
by tying in a knot. 

Kagele's method consisted in removing the circumference of 
the opening w T ith a knife or scissors, the edge of which was 
guarded by a shield, movable at pleasure; then introducing the 
thread sutures by a peculiar needle, one end of which was sup- 
ported on a ring, through which the finger could be slipped, 



76 VESICO-VAGINAL FISTULA. 

and near to the other extremity, or the point, was an eye for 
the thread. The point was guarded by the finger while 
being carried to the fistula, and after the sutures were passed 
the parts were drawn together by twisting their ends together 
and allowing them to hang out of the vagina. Not the least 
important part of his plan was the use of the silver catheter; 
but, singular enough, its utility was destroyed in a great 
measure by the attachment of a stopcock, only allowing the 
urine to flow at particular times. The same authority pro- 
posed the use of gilt or silver pins, and around them silk 
threads. He employed likewise the glover's suture ; and for 
stitching, a watch-spring with a needle point, and concealed 
in a La Forest canula. 

Flamant manifested most concern about paring the edges 
of the fistula, to accomplish which he advised the use of a 
knife guarded at the point to protect the adjoining parts. 
The attention of Le Roy was most directed to the same sub- 
ject; and hence we find him proposing different forms of 
cutting instruments, and also a fenestrated speculum, with 
hooks to unite the sides, as a substitute for the suture. 

Shrseger freshened the edges with a pair of curved scissors, 
deposited wax threads by means of curved needles, supported 
on a needle-holder, and made them secure by introducing the 
ends through a rosary of small wooden balls or beads, and 
making them fast by tying over a little cross-piece. The 
same surgeon used the glover's suture. 

Luke employed a bivalve speculum to expose the parts, 
angular knives to incise the borders of the fistula, hooks to 
draw it down, and curved needles to deposit the sutures. 

Malagodi used a leather thimble, which he placed on the 
left index finger, and, hooking it under the margins of the 
openings, pared the edges when thus stretched, the approxi- 
mation being made by silk threads introduced by curved 
needles, manipulated in the grasp of a needle-holder. To 
prevent urinary infiltration a catheter was worn in the blad- 
der, and the vagina stuffed with lint or charpie. 

Ehrman recommended scarifying or cauterizing the edges, 
and then bringing them together with sutures, passed by 



TREATMENT. 77 

curved needles, managed with a porte-aiguille. When he 
used cauterization, a tube was inserted into the vagina, and 
through it a brush, dipped in a mineral acid, was carried up 
to the fistulous opening. The speculum he employed was a 
trivalve, and his sutures were inserted by curved needles. 

Gosset, surgeon at one time to Newgate, London, operated 
successfully in 1834 on a case, by the following method: The 
edges were carefully pared; metallic threads, well gilded 
were introduced by curved needles, passed with a needle- 
holder, and the sides brought together and so retained by 
twisting the wires. To keep the bladder empty an elastic 
catheter was worn, and the patient requested to lie on the 
breast. It is worthy of notice here that this surgeon, in 
executing his operation, placed his patient on her elbows and 
knees. 

Kilian separated the walls of the vagina with blunt hooks; 
used a silver catheter, curved similar to the male instrument, 
to bring the fistula forward for incising; and with curved 
needles, directed by a Wutzer needle-holder, passed the 
requisite number of threads, which were secured by Desault's 
knot-tightener. 

Blasius advised a grooved suture. The margins of the 
fistula were fashioned with a sharp-pointed knife, as follows: 
Taking hold of one side with a hook or forceps, it was split 
longitudinally, or parallel with the long axis of the opening: 
then seizing the other and everting it, the knife was applied 
to its surfaces in such a manner as to give it a cuneiform or 
wedge-shaped form ; needles armed with thread sutures were 
next passed, drawing the wedge-shaped side into the gutter 
or slit of the opposite, constituting a tongue and groove (as 
he calls it) adjustment. He claims for this a more extended 
apposition or contact of raw surfaces. 

Lewzisky's operation consisted in inserting the stitches by 
means of a canula, traversed by a watch-spring, supporting a 
needle bearing a thread. ~ This instrument was carried into 
the bladder, and the needle made to project from the canula, 
puncturing the septum from the vesical towards the vaginal 
side. By repeating this process above and below the open- 



78 VESICOVAGINAL FISTULA. 

ing, the ends of the sutures were all brought into the vagina 
and secured on that side. This operation is similar in most 
respects to that of Nagele, and includes the entire thickness 
of the vesi co-vaginal wall. 

Colombat furnishes us with an operation much more re- 
markable for its ingenuity than utility. The chief novelty 
of his method consists in using a spiral needle, not unlike a 
corkscrew (Fig. 16), having a steel point, with an eye for the 

Fig. 16. 




Colombat needle. 

thread. At the other extremity, where it conjoins with the 
handle, there is a second eye, through which the ends of the 
thread are passed, after being wound about the spiral of the 
instrument. After vivifying the edges with a pair of cutting 
forceps, the needle is made, by a rotatory movement, to pierce 
one side of the fistula ; then the other, and so on, just as 
one would bore a gimlet, until its entire length was traversed, 
when by reversed turns it was removed, leaving the thread 
in its track, as represented in Figs. 17 and 18. This is a 

Fi£. 17. Fio-. 18. 





glover's suture. The ends of his threads were twisted to- 
gether and secured with sealing wax. Dieffenbach very 
facetiously remarks, this instrument only needs a clockwork 
attachment to go right. 

Deybers employed a wooden catheter, introduced through 
the urethra, to control the edges of the opening while being 
subjected to the knife. The stitching he effected by means 
of a curved tube inclosing an eyed stylet for the thread, and 
which was controlled by a spring protruding or withdrawing 



TREATMENT. 79 

the point at pleasure. The sutures he used were either silk 
or lead wire. 

Roux fixed the edges with a long pair of forceps while 
they were being incised, passed across them silver pins, and 
drew the wound together by winding about them threads 
similar to our twisted suture. 

Wuther incised the fistula with either curved scissors or a 
sickle-shaped knife, fixing it first with a hook, and used 
sometimes long-stemmed needles, sometimes short curved ones 
passed with a needle-holder like that of Roux's; and at other 
times insect-pins, surrounded with threads to bind the edges 
together. His patients during the operation kneeled, or were 
kept on their hands and knees, and the vagina exposed by 
introducing a hook speculum — really an instrument similar 
to the Sims speculum. In order to defend the wound against 
the action of the urine, and keep the bladder empty, the 
organ was opened above the pubes, a catheter introduced, 
and the patient kept upon her belly, buckled to a leather 
cushion in which a hole was cut out. On the sixth day his 
ligatures were removed, injections of cold water having been 
thrown into the bladder, through the catheter, and the vagina, 
through an oesophagus tube, every half-hour. In eighteen 
operations three cases were reported cured ; a success pro- 
nounced extraordinary, and greater than that of any other 
surgeon. 

Diefrenbach, to expose the fistula, used a bivalve speculum ; 
seized the margins with a hook or long forceps while they 
were being pared, and united them with the interrupted 
suture. The position in which he preferred having the pa- 
tient for the operation was on the back, and the catheter was 
used continuously to drain the bladder. In his hands the 
results were most discouraging. On one woman he operated 
eighteen times, and then failed to effect a cure. So great 
was his interest in the subject, that he gathered wards full 
of women afflicted with this malady, from all parts of the 
country, but, as he states himself, making very few cures. 

Beaumont, after paring the edges, introduced double 
threads ; through the loops on one side was inserted a cylin- 
der of some round substance parallel with the border of the 



80 VESICOVAGINAL FISTULA. 

opening, and along the other side a second, over which the 
free ends of the sutures were tied, forming a quilled suture. 

Thus far the fistula under consideration has proved more 
than a match for the skill of the ablest of the old world, and 
now we turn to American surgery to have our hopes revived 
and faith strengthened. 

In 1839 Dr. George Hayward, of Boston, reported a case, 1 
which he had succeeded in curing. His patient was a 
lady aged 34 years, in excellent health, and who had been 
delivered 15 years previous, with instruments, after being 
in labor three days, during which time no urine had been 
drawn from the bladder. A slough was the consequence, 
opening a communication between the vagina and bladder. 
Attempts had been made with the catheter and also by 
cauterization to close this fistula, but without success. Dr. 
Hayward operated on the 10th of May. The patient was 
placed on the edge of the table, upon her back, very much 
as in the position for lithotomy; the parts well dilated (he 
does not state how) ; a large bougie passed into the bladder 
and carried back to the fistula, by which he was able to bring 
it into view. Thus fixed, an incision was made round the 
opening with a scalpel, and after the bleeding ceased, the 
membrane of the vagina was dissected away from the bladder 
to the extent of three lines. Three silk threads were next 
introduced by curved needles through its sides, drawn to- 
gether and knotted firmly down ; a short silver catheter, 
prepared for the purpose, was placed in the bladder, and the 
patient put to bed. In five days she was examined, the 
stitches cut away, and the parts found to be solidly united. 
In 1851 Dr. Hayward published an account of eight addi- 
tional cases, making in all nine cases, three of whom had 
been cured after twenty operations. 2 

In these^ cases of Dr. Hayward there was nothing new, un- 
less it was the peculiar catheter. It had often been practised 
before, but in his hands was crowned with a success calcu- 
lated to inspire confidence in the curability of the affection. 

1 American Journal of the Medical Sciences, August, 1832. 

2 Boston Med. & Surg. Journal, vol. xliv., No. 11, April 16, 1859. 



TREATMENT. 81 

In 1847 Prof. Joseph Pancoast 1 succeeded in effecting two 
cures. The posterior or upper lip of the fistula was exposed 
by a Charriere speculum, and split one-half inch deep in a 
longitudinal direction ; with a pair of scissors and bistoury 
the lower lip was next pared into a wedge-shaped form, and 
this tongue of raw tissue drawn into the groove in the upper 
border by what he called his plastic suture. The bladder 
was kept empty by a gum-elastic catheter, and after the 
second day, injections of zinc were thrown into the vagina 
to give tone to the parts. On the fourth day a solution of 
the nitrate of silver was applied over the line of apposition, 
to favor union by granulation, where that by the first inten- 
tion failed. In this method we have a repetition of the plan 
of Blasius. 

In the same year Dr. John P. Mettauer published in the 
American Journal of the Medical Sciences, for July, 1847, the 
history of a fistula, which he cured by inserting leaden sutures 
after paring its circumference. The bowels were kept closed 
for eight days, and the stitches allowed to remain thirteen 
days, during which time a short catheter was worn in the 
bladder. The metallic thread used by the operator in this 
instance was undoubtedly the procuring cause of so fortunate 
a result. Just at this point commence the most important 
facts in the history of our subject. 

In 1852 Dr. J. Marion Sims, of Alabama, solved the whole 
difficulty, and placed this vexed and perplexed operation on 
a solid and substantial foundation. The discoveries which 
he advanced as peculiarly his own were the following : — 

1st. A method by which the vagina could be thoroughly 
explored, its capacity greatly increased, and the fistula made 
readily accessible. 

2d. The introduction of a suture which would remain a 
long time without inducing either irritation or ulceration. 

3d. A mode of keeping the bladder drained of the urine. 

The first was accomplished by placing the patient on the 
knees and elbows, the hips being elevated, and using a spec- 

1 American Journal of the Medical Sciences, Oct. 1842. Med. Exami- 
ner, May, 1847. 



82 VESICOVAGINAL FISTULA. 

ulum which, from its form, is called the duck-bill speculum ; 
the second, by substituting the ordinary thread with a 
metallic (silver) one, aided by leaden clamps; and the third, 
by a self-retaining catheter. 

There can be little doubt that Dr. Sims reached this im- 
portant combination of improvements quite independent, 
perhaps, of foreign aid ; yet by reference to the historical 
enumeration of methods which I have detailed, it will be 
found almost all have been conceived and executed by pre- 
decessors. In illustration of this, let them be examined in 
detail. 

First. The Position. — This was recommended and practised 
both by Chelius and Walter, the latter of whom employed a 
blunt hook for opening the vagina, which executed in a good 
measure the office of the duck-bill speculum. 

Second. The Suture Apparatus. — In 1834, Gosset, of Lon- 
don, employed the metallic thread ; Deyber also; the former 
gilded wire, the latter lead. Beaumont carried his sutures 
around little cylinders, placed one on each side of the fistula, 
thus resembling the clamps. 

Third. The self-retaining Catheter. — Dr. Mettauer employed, 
in his case, a short instrument which was worn in the blad- 
der during the cure: so that really all these novelties have, at 
some time or other, engaged the notice of surgeons during 
the long years of experiment and device which have marked 
the history of vaginal fistula. Still, however, the undivided 
honor of combining, modifying, and utilizing, all belongs, 
and only belongs to Dr. Sims. 

Dr. Sims's Operation. 

Position of the Patient. — A table is selected 2J by 4 feet, 
covered with folded comfortables ; on this the patient is 
placed, resting on her elbows and knees, the latter separated 
six or eight inches, the pelvis being elevated, and the shoul- 
ders depressed. An assistant on either side, placing a hand 
in the fold between the nates, the fingers extending quite to 
the greater labia, simultaneously draws them asunder. Tbe 
viscera gravitating toward the thorax, and the air rushing 
into the vagina on the separation of the walls of the vulva, 



DR. SIMS S OPERATION. 



83 



distend the canal so as to offer a very complete interior view. 
To increase its capacity for a more thorough exploration, the 
Sims speculum (Fig. 19) is next introduced, and drawn back 
toward the sacrum by one of the assistants. (Fig. 20.) 



Fig. 19. 




Vaginal speculum similar to Situs's — Bozerman's pattern. 
Fig. 20. 




Exhibits the speculum in situ, with the relative position of the organs. 

If the illumination is not sufficient, a mirror (Fig. 21) may 
be used to reflect the li^ht into the canal. 

Paring the Fistula. — For this purpose a small sharp hook 
or tenaculum is passed into the circumference of the fis- 
tula, and while thus brought into proper position, and 



84 



Fi«r. 21. 



VESICO VAGINAL FISTULA. 
Fisr. 22. 




Mirror to throw the sunlight 
into the vagina. 

made sufficiently tense, 
a long, sharp-pointed 
bistoury is applied. 
(Fig. 22.) If the vesi- 
cal mucous membrane 
concealed the margin 
of the fistula, inter- 
fering with its proper 
management, a soft 
sponge should be pass- 
ed through the open- 
ing into the bladder, 
and allowed to remain 
until the stitches are 
ready for adjusting. 
The lining membrane 
of the bladder he does 
not disturb, unless it 
protrudes through the 
opening in excess. 
When the fistula was 
very small he hooked 
the tenaculum through 
both sides, and raising 




Tenaculum fastened in the fistula, and the bistoury 
applied to its circumference. 



DR. SIMS S OPERATION. 



Fie:. 24. 



it up, cut out a circular portion with the bistoury. During 
the operation little mops (Fig. 23), to remove the blood, 
should be on hand. These are readily made by securing 
small bits of sponge to whalebone or rods of wood. 

Application of the Clamp Suture. — This may be divided into 
three stages: the introduction of the silver wires; the at- 
tachment of the clamps ; and the approximation of the 
wound, with the securing 
of the apparatus. 

First. Introduction of the 
Sutures. — In the execution 
of this he passed a silk 
thread through the eye of 
a long awl-shaped needle 
(Fig. 24), and entering it 
half an inch from the fresh- 
ened edge of the opening, 
carried it downward and 
forward across the wound, 
and bringing it out half an 
inch above the raw margin 
of the opposite side, taking 
care not to include the mu- 
cous membrane of the blad- 
der. As the needle passes 
through the distal side, the 
tissues will require support, 
that they press not away 
from the instrument, and 
thus counter-pressure is sup- 
plied by a blunt hook be- 
hind the needle (Fig. 25). 

As soon as the needle 
emerges, and the thread 
comes fairly into view, a 
long tenaculum is hooked 
into the loop, and one end 

drawn through (Fig. 26), A sponge mop. Needle for passing sutures. 



86 



Fig. 25. 



VESICOVAGINAL FISTULA. 

Fie. 26. 




The blunt hook between the 
needle and tissue to favor 
its passage. 



Exhibits the tenaculum drawing the thread 
through. 



after which the needle is withdrawn, leaving the suture in 
its track. In this manner the requisite number of threads 
are deposited across the wound. The next step consists in 
substituting the silver threads for the silk, which is readily 
accomplished by binding the end of the former into a crook 
or link, and making fast to it the distal end of the latter. 



DR. SIMS'S OPERATION. 



87 



By drawing on the proximal end of the thread the wire is 
towed into its place; the threads being only designed to 
favor the insertion of the wires. In this process a difficulty 



Fis\ 27. 



Fi<?. 28. 





Upper clamp attached. 

very naturally occurs — that of the 
threads or wires, as it may be, cutting 
into or even tearing out of the tissue, 
on the distal side of the wound, as 
they are pulled upon. To counteract 
this he employs a crescent-shaped 
fork to push the suture above the 
orifice while traction is being made. 
(Fig. 27.) The silver sutures being 
all passed, the second stage of the 
process consists in the 
Attachment of the Clamps. — Two little bars of silver or lead, 



A silver thread secured to tue 
silk one. with the fork in sicu 
to fnvor the pnssage through 
the upper punctures. 



VESICO-VAGLNAL FISTULA. 



a trifle longer than the fistula, are perforated with a number 
ot holes, corresponding to the number of sutures. Through 
these the upper end of each wire is passed, and fastened by 
widening it about the bar, or passing it through a shot. 
(Fig. 28.) This completed, the lower ends of 
Fig. 29. the wires are drawn upon, when the clamp 

will be carried into the vagina, and take its 
place above and parallel with the upper border 
of the wound. During this adjustment a 
fork of another kind (Fig. 29) is used as a 
pully, to prevent the wires cutting into the 
flesh. In the same manner, the other ends of 
the wires are passed through the second 
clamp. (Fig. 30.) 

The Adjustment — The proximal ends of the 
wires being drawn upon, and the clamp 
pushed up with the fork at the same time, 
the raw surfaces are brought in contact with 

Fie-. 30. 




The adjusting fork. 



Both clamps on the wires', and perforated 
shot behind the proximal one. 



each other, in doing which, care and judgment are requisite 
that they be pressed together sufficiently tight to prevent 



DR. SIMS'S OPERATION. 



89 



gaping, and yet not so forcible as to endanger strangulation 
or ulceration. To maintain the apparatus in position, a per- 
forated shot is passed down each wire, and being pressed 



Fie. 31. 




Shot compressor. 

against the clamp, is then fastened by compression with a 
strong pair of forceps. (Fig. 31.) The wires are next cut off 
short, and bent over the shot. 



Fiar. 32. 




Exhibits the wound adjusted with the suture apparatus. 

The appearance of the wound, when adjusted, with the 
suture apparatus in position, is represented in Fig. 32. 

7 



90 VESICO-VAGINAL FISTULA. 

The After-treatment. — The operation being completed, the 
patient is placed in bed, on the back, a self-retaining catheter 
placed in the bladder (Fig. 33), and a full dose of opium 



Fiff. 33 




Self-retaining catheter of Sims. 

administered, to be repeated as often as may be necessary 
to keep the bowels quiet. The diet is to consist of crackers 
and coffee or tea. During the progress of the case, the 
vulva and other portions of the external genitalia are to 
be bathed with cold water, a bed-pan being placed under 
the nates, to collect the fluid as it runs from her person. 
The urine is to be received on old cloths as it drops from 
the catheter. On the ninth or tenth day the clamps and 
sutures are to be removed, and, if well, the patient required 
to wear the catheter for several days longer. About the 
twelfth or fifteenth day the bowels should be opened by some 
mild cathartic. 

Such are the general features of Dr. Sims's operation, and 
from this dates the successful surgical management of vesico- 
vaginal fistula. 

Dr. Sims's Later Operation. 

To the clamp there are objections, and these were soon 
discovered by Dr. Sims, and the operation so modified as to 
add greatly to its simplicity and perfection. The modifica- 
tions consist in the introduction of the metallic threads with- 
out those of the silk, and dispensing entirely with the 
clamps, adjusting the wound and securing the wires by 
twisting alone, which he accomplishes by drawing, with a 



DR. SIMS'S LATER OPERATION. 



91 



pair of forceps, the ends of the wire through the slit at the 
end of his adjuster (Fig. 34), and then, while thus firmly 



Fis. 34. 




Sims's method of coaptating and securing wires by an adjuster and force] 



held, the forceps, by a rotary movement, twirls the wires 
about each other, so as to make them secure. 



92 



VESICOVAGINAL FISTULA. 



Operation of Dr. Nathan Bozemax, 

FORMERLY OF ALABAMA. 

The name of Dr. Bozeman is well known, both in this 
country and abroad, in connection with vesico-vaginal fistula. 
Several papers from his pen have appeared 
on the subject, all proving unusual dexterity 
and success as an operator. The chief 
novelty in his method is what he terms the 
button suture (Fig. 35), composed of a piece 
of thin lead cut to fit the opening, and 



Fig. 35. 




Bozeman'slead 
button. 



having in it small holes answering to the 



Fig. 36. Fig. 37. Fig. 38. Fig. 39. 




DR. BOZEMAN S OPERATION. 



93 



Fis:. 41. 



number of wire sutures employed ; also leaden crotchets to 
secure the button. The patient is placed in the position 
recommended by Sims; a duck-bill 
Bozeman speculum introduced; and 
while the parts are controlled by a 
long tenaculum or forceps, the edges 
are pared by straight and curved bis- 
touries — sometimes using the curved 
scissors. (See Figs. 36, 37, 38, 39, 40.) 
This done, the requisite number of 
silk threads are introduced with short, 
straight, spear-pointed needles, from 
half an inch to one inch in length, 
grasped in the jaws of a needle-holder. 
(Fig. 41.) The needle is entered some 
distance from the freshened border, 
and carried obliquely through, first 
the proximal side of the fistula, pene- 
trating as deep as the vesical mucous 
membrane, and then, after being ad- 
justed to the needle-holder, through 
the distal side, being drawn through 
with a pair of long forceps, counter- 
pressure being made with a blunt 
hook, similar to Sims's instrument. 
The threads being all passed, each one 
is securely fastened by its lower end to a 
silver wire, and as the one is drawn out 
the other takes its place, a fork being 
used, as in Sims's method, to guide the 
sutures and support the soft parts. 

The next step consists in passing 
both ends of each suture through an 
instrument called an adjuster (Fig. 42) ? 
and drawing on the wire, as it is run 
down, the wound is brought together 
and a set given to the thread, which 
contributes to so maintain it. (Fig. 43.) 



Bozeman's needle-holler — a 
long stem with two claws at 
its extremity, with a canula 
to slide up and down, clos- 
ing and opening the jaws. 
Also examples of the Boze- 
man needle. 



u 



VESICOVAGINAL FISTULA. 
Fiff. 42. 




Fiff. 43. 



Adjuster. 

The wires are next passed through the perforations in the 
lead button, and the latter pressed down upon the line of 

approximation, and made to conform 
to the surface against which it rests 
by means of an instrument represented 
in Fig. 44. 

To secure the button firmly in 
place, pieces of lead or crotchets are 
run down the wires (Fig. 45) and 
compressed by a pair of strong for- 
ceps, both on wires and button. The 
operation is finished by cutting off 
the wires a short distance above the 
crotchets, and turning an end down 
on either side. (Fig. 46.) The patient is placed in bed, on 
her back, the catheter introduced, the bowels kept closed by 
opium, and an unirritating diet allowed. 

Fis:. 44. 




The sutures after being passed 
through the adjuster. 




Bozeinan's instrument, having an angular and concave extremity, to model 
the button to the surface of the vesico-vaginal septum. 



Fiff. 45. 



Fiff. 46. 





Button and crotchets 
adjusted, wires cut 
and turned down. 



Exhibits the crotchets being 
passed down the wires. 



DR. SIMPSON S OPERATION. 



95 



Operation of Dr. J. Hunter McGuire, 

FORMERLY OF PHILADELPHIA. 

The patient being placed in the position recommended by 
Sims, the edges are to be pared with a long-handled bistoury, 
and brought together with the instrument delineated in 
Fig. 47. This consists of 
a plate of silver, having a Fi S- 47 - 

hole near each extremity, 
and three needles, slight- 
ly curved, soldered to its 
front surface, a second sil- 
ver plate, of the same size 
and shape as the first, hav- 
ing fastened to each end 
a thread-screw, and three 
holes corresponding in po- 
sition to the three needles 
on the other plate, and 
lastly, two female screws. 

Application. — With a 
strong pair of forceps the 

plate supporting the needles is grasped, their points passed 
through the posterior lip of the fistula, and brought out 
through the anterior one. Through the perforations at either 
end of this plate are next passed the thread-screws of the 
other plate, and through its perforations the extremities of 
the needles. The female screws are next run down the 
thread, forcing the clamp together, until the edges are in 
close contact. 




Representing McGuire's instrument for 
vesico- vaginal fistula. 



Operation of the late Dr. J. Y. Simpson, 

OF EDINBURGH. 

The operation of this distinguished Scotchman, certainly 
one of the representative medical men of his age, differs 
chiefly in substituting for the Bozeman button a wire splint, 
prepared as follows : He takes ten or fifteen strands of metallic 
thread and twists them into a cord, the ends of which are 



96 



VESICO-VAGIXAL FISTULA. 



Fig. 48 



Fig. 49. 




Dr. Simpson's needle, with a wire in- 
serted. Simpson's crotchet and hook. 



then doubled over each other 
and plaited round into the 
form of a circle, which may, 
being very flexible, be pressed 
into any figure desired. With 
an awl or any sharp-pointed 
instrument the required num- 
ber of holes may be made, by 
passing it through among the 
wires. These perforations are 
for the iron thread sutures. 
For the introduction of the 
sutures Dr. Simpson uses an 
ingenious needle (Fig. 48), to- 
gether with a crotchet (Fig. 
49), and a hook (Fig. 50). 

The needle consists of a 
hollow tube, with a needle- 
point, one opening being near 
the end, and the other near 
where the handle and shank 
join. 

The mode of using is 
readily understood. The wire 
thread being pushed within 
a short distance of the upper 
orifice, the needle is carried 
through both sides of the 
fistula, after which the thread 
is thrust forward. As soon 
as it appears, it is to be seized 
with a pair of forceps, and 
held while the needle is being 
withdrawn, thus leaving the 
suture in situ. By a repeti- 
tion of this process the requi- 
site number are introduced. 
He prefers the iron wire, as 



dr. Simpson's operation. 



97 



more easily managed than silver. His sutures are next 
passed through the openings in the wire splint (Fig. 51), the 
latter being pressed down over the line of apposition, and 
the wires secured by twisting with his wire-twister (Fig. 52), 
constructed on a plan which was suggested by Dr. Coghill. 



Fig. 51. 
I I 



Fia:. 53. 



Fisr. 




Simpson's wire splint, the threads being carried 
through the openings in it. 

Fig. 54. 





Simpson's splint adjusted, wires secured across the 
lower bar. 



Simpson's wire-twister. 
The same, with the win 
in and partly twisted. 



The ends of the metallic threads are next clipped off close 
to the splint (Fig. 54), and the after-treatment conducted on 
the same principle as that of other operators. 



98 VESICO-VAGINAL FISTULA. 

Figs, from 20 to 34 inclusive have been copied from Dr. 
Sims's paper on Vesico- Vaginal Fistula ; from 35 to 46 from 
Dr. Bozeman's illustrations of his method ; and from 48 to 
54 from Dr. Simpson's contributions to the same subject. 

Operation of Dr. Isaac Baker Brown. 

For paring the fistula he uses straight and angular knives ; 
for the passage of the metallic sutures, Simpson's needle ; and 
for securing the threads, little crotchets or clamps of lead, 
run down and compressed with a strong pair of forceps. His 
operation dates 1860. 

Operation of Dr. Robert Battey. 

The peculiarity of Dr. Battey's method consists in a 
metallic (lead) button (Fig. 55), having a series of holes on 

Fig. 55. 

L_n_i L_ji_J 

Battey's Button. 

one border, and on the other a corresponding number of slits. 
The upper ends of the wire after being inserted are passed 
through the holes, the other ends forced into the slits, and 
both fastened by twisting them about each other. He claims 
for it a water-tight. adjustment. 

Operation of Collis, 

OF DUBLIX. 

This method, described in 1862, consists in splitting the 
vesico-vaginal septum along the entire circumference of the 
fistula ; turning the vesical side toward the bladder, and the 
vaginal side toward the vagina; the sutures he employs are 
silk, and introduced as double threads, with Liston's needles 
secured on long handles. When the threads are all inserted 
there will be a row of loops on one (the upper) side, and two 
free ends on the other side of the fistula. A vulcanized quill 
is next passed through the loops above, and a second placed 
along the lower border of the opening, and the approxima- 
tion effected by tying the free ends of the threads firmly 
around it; it is a quilled suture. 



AUTHOR S OPERATION. 



99 



Operation of Dr. Alfred Meadows, 

PHYSICIAN-ACCOUCHEUR TO THE GENERAL LYING-IN HOSPITAL, LONDON. 

The novelty of this method consists in allowing the patient, 
after the parts are pared, and closed with silver threads, to 
rise and go about as usual, dispensing altogether with the 
catheter. He publishes two cases, which it is alleged were 
treated successfully in this way. I should not feel disposed 
to subject a patient to such a treatment without some further 
accumulation of data. 



Author's Operation. 

Having presented the various operations in historical suc- 
cession, I proceed to state the plan of treatment practised by 
myself for several years, with results the most satisfactory. 
Nothing original is claimed for the method. Except in a 
few particulars, it does not differ from modes pursued by others. 

Arrangements for the Operation. — Among the first things to 
be attended to is the bed on which the patient is to lie. This 
should be a firm mattress ; but should the circumstances of 
the patient be such as not to command this, a feather bed 
may be well beaten down and covered with two or three 
comfortables, so as to give it a certain degree of solidity. 
Over that part where the hips are to rest there should be 
spread a strip of oil-cloth, and over this a folded sheet, the 
object being to protect the 
bed. A low stool should 
be procured and turned 
upon its side, over which 
should be placed one or 
two folded blankets, and 
over these again a piece 
of oil-cloth, the whole to 
be secured by a few turns 
of a roller. (Fig. 56.) This 

. Stool covered, over which to place the patient. 

forms an excellent sup- 
port, across which the patient is to be turned. There will be 
required two basins, one bucket for cleansing, and another for 




100 VESICOVAGINAL FISTULA. 

the bloody water, several mops or sponges ; readily formed by 
securely tying small pieces of soft clean sponge to the ends of 
sticks or pieces of whalebone ; a six or eight-ounce syringe, 
and some pieces of ice. There is some difference of opinion 
as to the exhibition of an anaesthetic. In no operation do I 
think its exhibition more imperative than in vaginal fistula. 
The position and exposure are calculated to shock the feelings 
of any female possessed of ordinary sensibility, and I have in all 
cases administered this agent with the most satisfactory result. 

Assistants. — There will be required four assistants; one for 
the sponges, one for each lower extremity, and one for the 
anaesthetic. As such an operation is rarely completed in less 
than half an hour, and may be prolonged to even two hours, 
the assistant having charge of the anaesthetic should be per- 
fectly familiar with his duty. 

Time to Operate, — As a good light is all-important to the 
successful execution of this operation, the forenoon of a clear 
clay should be selected, and a room whose windows have a 
northern or southern exposure. 

Instruments. — The instruments which have been and are 
still being invented for this operation constitute a most for- 
midable armamentarium. I shall content myself by pre- 
senting a list of such as compose my own case, and which I 
have found to answer every purpose. 

A duck-bill speculum (Fig. 57); two long-handled scalpels 
(Fig. 58); one pair of my long rat-toothed forceps, slightly 
curved, with an attachment at the end of the handle, em- 
bodying the adjustor, for running down the wires, and the 
crotchet to favor by counter-pressure the passage of the needle 
through the distal side of the fistula (Fig. 59) ; a needle-holder 
which can with one hand be detached from the ueedle, or 
again made to grasp it, and by which the needle can be in- 
troduced at any angle (Fig. 60); one pair of long scissors, 
curved a little on the flat (Fig. 61); a shot compressor (Fig. 
62); this instrument, to be efficient, should have strong 
handles, and the articulation less than half an inch from their 
extremities; a shot perforator (Fig. 63); two sigmoid self- 
retaining catheters (Fig. 64); the openings in which should 






Fiff. 57. 




author's operation. 
Fig. 58. Fig. 59. 

(1 L 



101 



Fiff. 60. 




Fig. 61. 



Fig. 62. 



Fig. 63. Fig. 64. 







102 VESICO-VAGINAL FISTULA. 

be very small, otherwise the mucous membrane of the blad- 
der will insinuate itself through them, and become strangu- 
lated, rendering its withdrawal impossible without tearing 
the incarcerated portions; one dozen of needles; these should 
be constructed with great care, seven-eighths of an inch in 
length, slightly curved for one-fourth of an inch at the ex- 
tremity, the cutting-edge confined only to the extent of the 
curve, and sufficiently wide to allow the proximal part to pass 
without tugging and pulling, as is too often the case (Fig. 65). 

Fig. 65. 



The eye should be well sunken, so as to bury the thread, and 
the whole so tempered as to bend rather than break ; fine silver 
wire ; some ~No. 3 shot; and twelve or fourteen inches of light 
gum-elastic tubing, to slip over the end of the catheter, and 
thus convey the urine to a bottle or other vessel placed be- 
tween the patient's limbs. 

Operation. 

The patient, having removed all her clothing, save a chemise 
and night-gown, lies down upon the bed, and is brought 
under the influence of the anaesthetic, nothing having been 
communicated to her about the position in which she is to be 
placed. When sufficiently unconscious, the stool, prepared 
as directed, is placed across the foot or side of the bed, and 
the patient carefully' lifted and placed over it, resting on her 
abdomen, two or three pillows being laid under her breast 
and head in such a way as to form an inclined plane. The 
head must be turned on one side, and a free access of fresh 
air admitted to her face. The person having charge of the 
anaesthetic must take his position so as to have a full com- 
mand of the pulse and countenance, keeping her perfectly 
passive, without profoundly impressing her. There are 
periods in the operation when very little need be given, as 
when the surgeon is waiting for the bleeding to cease ; and 
again, when the apposition and adjustment are being effected; 
at such times very little pain is inflicted. The legs, being 
next flexed upon the thighs, are given over to assistants. 



OPERATION. 



103 



The operator now takes the speculum, smeared with oil, and 
introducing it into the vagina, commits it to one of the 
assistants having charge of the limbs, who draws it firmly 
toward the rectum, when the air, entering the vagina, ex- 
pands the tube in the most satisfactory manner. (Fig. 66.) 

Fig. 66. 







Exhibits the woman resting on her abdomen over the stool placed across the bed, 
and the assistants supporting the limbs ; one of them also holds the speculum, 
which has been passed into the vagina. 

The surgeon now takes his seat in a position to command a 
full view of the fistula, and seizing its lower margin with the 
forceps, enters the knife from three-eighths to half an inch 
from the opening, bringing it out just short of the vesical 
mucous membrane, and by successive sawing movements 
paring away until the entire circumference of the fistula has 
been freshened. Should the mucous membrane of the blad- 
der protrude, a piece of sponge may be pressed through the 
opening to keep it out of the way. The greatest difficulty 
in executing this part of the operation will be experienced at 



104 VESICOVAGINAL FISTULA. 

the angles or commissures of the opening, and too much care 
cannot be observed that no point be overlooked. If it is 
properly done, there should be at least three-eighths of an 
inch, or more, of oblique raw surface visible everywhere 
around the fistulous opening. The tendency to inversion of 
the vagino-vesical septum is so great that, unless a consider- 
able extent of tissue is removed, there will be danger of not 
having a sufficient amount of raw surfaces apposed to secure 
adhesion. There will be cases and situations in this freshen- 
ing process where the scissors come in more advantageously 
than the knife ; such will naturally occur to the surgeon as 
he proceeds. Where the fistula is very small, receiving, for 
instance, only the end of an ordinary probe, some advise 
transfixing with a long awl-shaped instrument, and, raising 
the sides, by a single stroke of the knife cut out a sufficient 
amount of tissue. There is a very ingenious instrument (the 
author of which I cannot recall) (Fig. 67), with a conical ex- 
tremity standing at an angle with the shank, the base of 

Fig. 67. 




which is surrounded with sharp teeth, designed for control- 
ling the edges of such fistulas. The apex of the cone is in- 
serted into the opening, and pressed through ; then, by with- 
drawing it, the teeth become fixed into the circumference, 
when the knife may readily excise at a stroke the included 
tissue. 

There is another instrument (Mr. Hilliard's, of Glasgow) 
designed to secure the edges of large fistulas while being 
pared, and which consists of a long shank with a small 
thread at its extremity, on which may be secured various 
sized forks for transfixing, and on this shank a sliding rod, 
bearing a bar which may be pushed forward, and then drawn 
hack between the forks, so as to compress and secure the in- 
cluded tissue. Figs. 68 and 69 exhibit the instrument and 
its application. There is no objection to having all these 
instruments, if the taste and the circumstances of the surgeon 



OPERATION. 



105 



of 
be 



allow it; but that such are essential or 
even necessary to the proper execution 
of the operation is certainly not correct. 

Arrest of Hemorrhage. — The bleeding 
which follows the foregoing process is 
not generally very profuse, stopping 
under the application of cold water, 
or a lump of ice inserted into the 
or even under the styptic influence 
atmosphere; but occasionally cases will 
with where the discharge of blood proves both 
copious and persistent. To control such irregu- 
larities I have found a small stream of cold water, 
steadily directed on the parts from a large syringe, 
singularly efficacious. Should this not succeed, 
the stitches should be inserted and the edges drawn 
firmly together, when it will cease, just as the 
approximation in a case of hare-lip arrests the 
hemorrhage. 

The Direction of Approximation. — Most operators 
favor an approximation of the sides of the fistula trans- 
versely, yet there are no reasons why they may not be closed 
longitudinally. Case 15 is an example in point. Such con- 
ditions as the following will indicate such an apposition : as 
when the fistula runs to any great extent longitudinally; or 
when it is low, and either so great a loss of substance or so 
unyielding a character of tissue as to make too much traction 
when brought together on the lower wall of the urethra, 
endangering a subsequent incontinence of urine. 

Introduction of the Sutures. — This is regarded by many as 
the most difficult part of the operation. The needle bearing 
the wire is placed in the grasp of the needle-holder, and 
whilst the proximal border of the fistula is steadied by the 
forceps, is entered at the middle of the wound, three-eighths 
of an inch from the freshened surface, brought out at the 
mucous membrane of the bladder (not including it), carried 
across the opening, made to enter the opposite side, and 
emerge the same distance above its raw surface. The needle- 




106 



VESICOVAGINAL FISTULA. 



holder is now disengaged from the needle by simply pressing 
the upper blade of the instrument while the spring is being 
pressed forward by the thumb, made to seize the extremity 
now through the upper border of the fistula, and while the 
parts are supported, by applying to them the hook at the end 
of the forceps (Fig. 70), the needle is drawn through, turned, 



Fig. 70. 



Fig. 71, 




Exhibits the threads passed. 

and brought out of the vagina. When 
the sides of the opening are too wide 
apart, the needle cannot be made to 
penetrate both at once, and therefore it 
must be drawn through them in succes- 
sion. In this manner the requisite 
number of threads are inserted, the 
distance between them being a trifle 
less than one-fourth of an inch. (Fig. 
71.) As each is deposited in its proper 
place the needle is to be removed, the 
ends of the wire twisted together, and 
given in charge of one of the assistants 
supporting the thighs. 

Adjustment — In the important stage 
of the adjustment the wire first inserted 
is separated from the others and the 
ends passed through the hole of the 
adjuster at the end of the forceps. As 
the latter is slid down, the wire is drawn 
upon until the edges of the wound are brought into accurate 



O 

Needle in the grasp of the 
needle-holder carried 
through the fistula, and 
the hook at the end of 
the forceps placed be- 
tween the tissues and its 
point, to favor its pass- 
age by counter-pressure. 



OPERATION. 107 

contact. The set which the wire thus obtains is sufficient of 
itself temporarily to maintain the apposition. All of the 
threads are subjected successively to this process, and while 
being done care must be observed that the edges be properly 
everted so as to secure the contact of raw surfaces, and also 
that no clot be permitted to lie between them. 

The next step is to secure the sutures permanently, and for 
this purpose it has been my almost uniform practice to use 
perforated pellets of shot. These are run down the wires, 
then seized with the strong compressing forceps, and while 
the metallic threads are being drawn upon, pressed firmly 
against the line of adjustment, and then compressed so as 
securely to maintain their position. The sutures are next 
cut off close to the shot, leaving no projecting ends to irritate 
the soft parts (Fig. 72), the speculum withdrawn, the blood 
sponged away, and the patient placed on her back on the 

Fig. 72. 




Exhibits the edges of the wound apposed, the shot compressed on the wires, 
and the latter cut off. 

bed prepared for her reception, after which the catheter is to 
be introduced into the bladder and carefully watched to see 
if the urine flows freely through its canal. In order to keep 
the clothing of the patient and the bed perfectly dry, a light 
piece of gum-elastic tubing may be drawn over the end of 
the catheter, and its other extremity inserted into a bottle 
which shall lie between the patient's limbs; or a small earthen 
vessel or cup may be placed beneath the instrument, and 
receive the urine as it drops from its extremity. 

After-treatment. — Too much importance cannot be attached 
to the after-management of the case, as on this will depend, 
in a great degree, the success of the operation. The nurse 
should understand the manner of introducino; and removing* 
the catheter; if she does not, five minutes' instruction, by 



108 VESICO-VAGINAL FISTULA. 

showing her the mode, will suffice to enable her to do so, 
unless she be unusually dull of apprehension or imitation. 
It should be examined frequently to see that no obstruction 
exists, that it does not become misplaced, and that the urine 
drops freely. This is imperative, for it often happens for the 
first twelve or twenty-four hours that small coaguhe of blood 
are expelled from the bladder, and which may obstruct the 
instrument. Two catheters should be always on hand, so 
that one may be introduced immediately on the withdrawal 
of the other. After thirty-six or forty-eight hours, twice a 
day will be sufficient to change the instrument, in the morn- 
ing and at bedtime ; and it can best be cleared of mucus and 
other matters by inserting the nozzle of a syringe into one 
end and forcing through it a stream of water. If the blad- 
der is kept perfectly empty, the collapsed state of its walls 
will prevent all tension on the sutures, and diminish greatly 
the chances of urine getting between the edges of the wound, 
an accident which will almost always defeat the union. The 
position best suited to the patient is that on the back, 
although there are no objections to her turning for a 
short time on the side to relieve a sense of weariness or 
discomfort. 

The next important thought is to lock up the bowels and 
keep her free from all pain and uneasiness. For these ends 
we have no better agent than opium. One or two grains 
should be given as soon as she is adjusted in bed, after which 
from a third to half a grain three times a day, for five or six 
days, will answer. From this until the removal of the 
stitches, the fourth of a grain, morning, noon, and night, 
will maintain the effect produced. I do not think there is 
any advantage in exhibiting this drug beyond what is just 
sufficient to keep the bowels quiet; more than this tends to 
impair the digestion, disturb the secretions, and destroy the 
appetite. Occasionally the patient will be seized with an 
uncontrollable desire to bear down, or an involuntary con- 
traction of the bladder, often driving the catheter from the 
urethra ; in such conditions we must resort to enemata, con- 
sisting of two or three tablespoonfuls of flaxseed tea or 



OPERATION. 109 

starch-water, with forty drops of laudanum, repeated once or 
twice in the twenty-four hours, if necessary. ~No injections 
of water into the vagina should be practised, as directed by 
some ; nor any explorations with the finger ; the vaginal 
mucus which collects about the wound and the sutures does 
no harm whatever. Should the patient be annoyed with 
tympanitic distension of the abdomen, which not unfre- 
quently occurs, a little camphor-water and aromatic spirits 
of ammonia may be given, or a little turpentine in mucilage 
of gum acacia from time to time. 

Diet — The patient should be allowed a liberal but unirri- 
tating diet. Milk, soft-boiled eggs, cream toast, chicken or 
beef broth, mutton chop, with coffee and tea, offer a suffi- 
cient list from which to select her food. 

Removal of the Sutures. — On the eighth or ninth day after 
the operation the stitches should be removed, and for this 
purpose the patient may be placed on the side, her limbs 
well drawn up, and hips over the edge of the bed, before a 
good light ; or she may rest on her knees and elbow. The 
removal of the sutures not being painful, the administration 
of an anaesthetic is unnecessary, unless the patient be timid 
and shrink from the exposure ; in which event it should be 
given. The number of assistants requisite for the object in 
view will be determined by the taking or not taking an 
anaesthetic. In the former, there will be needed one to take 
charge of the ether or chloroform, and two to support the 
limbs and manage the speculum. In the other case a single 
assistant will be sufficient. The catheter being removed, 
the patient is placed in position and the speculum inserted 
and given to the assistant. The parts being satisfactorily 
exposed, the surgeon clears away the mucus from the sutures 
with a piece of moistened sponge; then taking hold of a 
shot with the long forceps, lifts it from the parts until the 
wire is distinctly seen, and with the scissors clips it on the 
proximal side (Fig. 73), straightening the end at the same time 
by pressing it outward with the blade of the instrument. 
This done, plant the blade of the scissors against the loop on 
the distal side, and drawing on the shot with the forceps the 



110 



VESICO-VAGINAL FISTULA. 



suture will come away by revolving about the blade of the 
scissors as a point d'appui, (Fig. 74.) 



Fig. 73. 



Fisr. 74. 




Exhibits one of the 
stitches after its 
removal, with the 
shot attached. 
The loop should 
be represented 
more open. 



Shows the suture seized with the forceps and being clipped by the scissors. 
From Simpson's work on Diseases of Women. 



The detail given in what may seem a very simple matter 
will be appreciated when the reader who has not, may have 
occasion to perform the operation. If neatly executed it 
will save the patient some sharp pain, and not endanger the 



OPERATION. Ill 

laceration of the cicatrix. The stitches being all removed 
after the manner just explained, the result will be revealed ; 
if favorable, the patient is to be replaced in bed and the 
catheter again introduced. , 

After two or three days the bowels should be opened by 
administering a teaspoonful of castor oil or a seidlitz powder 
every four or five hours, until a free evacuation is procured. 
The object in thus exhibiting the cathartic is to thoroughly 
liquefy or soften the fecal accumulations and prevent tension 
or straining during defecation. This result may be promoted 
by the employment of an enema of tepid water just before 
the evacuation. Five or six days after the removal of the 
stitches the patient must continue in bed, and wear the 
catheter, in order to take off all tension from the cicatrix, 
and allow it to attain considerable consolidation. After this 
the instrument may be removed and she may be allowed to 
walk about, remembering to pass the urine frequently and 
not allow the bladder for several weeks to become distended. 
Should the union not have taken place, and a considerable 
portion of the fistula remain unclosed, the catheter may be 
removed at once, the bowels opened, and the patient allowed 
to rise and go about as usual. When it is discovered that 
union has taken place save at a single point, so small, for 
instance, as to be readity closed by a single stitch, introduce 
at once that stitch, scarify well the edges and approximate as 
before ; continuing the management of the case in all respects 
as in the primary operation, for six or eight days longer; 
the probabilities are it will succeed. In one of my cases 
(Case 3) it was so done, and with complete success. 'No ap- 
prehension need be entertained in regard to keeping the 
bowels so long confined. 

Causes of Failure. — These will be found referable to some 
one of the causes enumerated below. 1st. Imperfect freshen- 
ing of the margins of the fistula. 2d. Mal-adjustment. 3d. 
Insufficient tissue from loss of substance, thereby rendering 
the permanency of the sutures uncertain. 4th. Diarrhoea 
accompanied with tenesmus. 5th. Soft state of the tissues, 
permitting the sutures to cut through readily. 6th. En- 



112 VESICO-VAGINAL FISTULA. 

feebled state of the health. 7th. Thin condition of the sides 
of the opening. 8th. Proximity to the cervix uteri. 

In regard to the first and second, the fault, being with the 
operator, can only be remedied by care and experience. The 
third is not always incapable of being remedied ; much may 
be done by deep stitches, incisions to relieve tension, and, 
rather than abandon the case as hopeless, a plastic operation 
as practised by Jobert, taking a flap from the inner surface 
of the labium. Should these fail, then it would be better, 
rather than allow the woman to remain in so miserable a 
condition, to freshen the outlet of the vagina and close up 
the canal, making a common cavity of it and the bladder. 
The fourth complication (diarrhoea and tenesmus) will be best 
met by enemata of laudanum or suppositories of opium. 
The sixth (feeble health) by tonics, nutritious diet, and pure 
air. Seventh (thin edges of the fistula) ; these may be greatly 
improved by scarifications and the application of the nitrate 
of silver every three or four days to the circumference of the 
opening. Eighth (proximity to the cervix uteri); when the 
fistula is situated in or extends to the cul-de-sac between the 
vagina and the anterior part of the cervix, any operation for 
its closure including only the vesico-vaginal septum will be 
likely to prove abortive. To obviate this difficulty when the 
ordinary method fails, the anterior semi-circumference of the 
cervix should be freshened, and the vesico-vaginal, similarly 
treated, stitched to it, thus turning the os into the bladder. 
In one of my cases (Case 2) such a plan was successfully 
adopted, and the woman continued to menstruate regularly 
through the bladder without any inconvenience whatever. 

Failure ought not in any way to discourage either patient 
or the surgeon. The rule is to operate until the case is cured, 
as such a consummation is certain, unless there be some un- 
usual state of things present. One caution is necessary here : 
The operation should not be repeated until at least six weeks 
have elapsed. 

Sequels. — There sometimes follows a successful closure of 
the fistula a certain degree of incontinence of urine, which 
is due generally to one of two causes. First, loss of power 



REPORT OF CASES. 113 

in the sphincter vesicae, permitting the urine to escape when 
the bladder is distended, or during coughing, sneezing, or 
even laughing. This condition may follow when fistula has 
been at the neck of the bladder. The second cause is short- 
ening of the lower wall of the urethra, with a patulous 
condition of the meatus — as in cases where the opening is 
low down, with such a loss of substance that when the 
stitches are inserted and the parts drawn together, the 
traction produces the effect already stated on the urinary 
canal. 

To remedy these defects, tonics, cantharides, and strychnia 
have been prescribed; yet, after all, time is the great restorer, 
as the parts tend gradually to assume their original condition. 
Should the incontinence be so great as to produce much dis- 
comfort, an elastic ring pessary may be passed within the 
orifice of the vagina. In one case (Case 14) I had to resort 
to this, with the most complete success. 

Report of Cases of Yesico- Vaginal Fistula Successfully 
Treated, and which have furnished the basis of the 
previous Papers. 

Case I. — F. H. was admitted into the Philadelphia Hospital, 
Blockley, suffering from a vesico- vaginal fistula. The fol- 
lowing account of the accident was obtained from the patient: 
In January, 1858, she gave birth to a child. Her labor was 
exceedingly difficult and prolonged, to aid which ergot was 
freely administered by her medical attendant. After de- 
livery, for several days she was unable to pass urine, which 
continuing to accumulate, and not being relieved by instru- 
mental interference, she suddenly felt a large gush of water 
escaping from the vagina, since which time the urine con- 
tinued to flow by this route. In May, 1858, her physician 
performed an operation for her relief. This failing, a second 
was tried two or three weeks subsequently, with a similar 
result. The operation adopted was, I presume, that of Dr. 
Sims, with the addition of the Bozeman button, as she de- 
scribed the employment of silver wires and a lead plate. 
Since the accident she informs me she has not menstruated ; 



114 VESICOVAGINAL FISTULA. 

but alleges that when the period comes round a very copious 
flow of urine takes place and continues for two or three days. 
I was invited to see her, July 1st, 1859, by Dr. R. K. Smith, 
Chief Resident Physician, and in company with himself and 
Dr. El wood Wilson, made an examination. An extensive 
transverse rent was discovered, extending from one side of 
the vagina to the other, and situated at the bas fond of the 
bladder. Through this protruded a considerable mass of the 
mucous membrane of the bladder. At the request of Dr. 
Smith, and her own earnest entreaty, I consented to attempt 
her relief by an operation. 

On the 23d of August it was performed in the presence of 
Drs. Smith, Wilson, Levis, McClellan, Darby, Nichols, and 
the internes of the house, the bowels having the day previous 
been well emptied. The steps of the operation consisted in 
placing the patient under the influence of ether, turning her 
over, supported on the arms and knees, and exposing the 
fistula by inserting rectangular or lever speculae along the 
walls of the vagina, which enabled the assistants to draw 
the parts well asunder. The edge of the fistula was 
next seized with a pair of long rat-toothed forceps, and well 
pared by means of a long-handled straight bistoury. As 
soon as the bleeding ceased, nine stitches of silver thread were 
inserted, the needles being guided by the needle-holder of Mr. 
Gemrig (see Fig. 60, page 101). The wires being brought out 
of the vagina, the opening was drawn together by passing the 
two ends of each through an adjustor, which was slid down 
to the wound, while the threads were firmly maintained be- 
tween the fingers. Not being altogether satisfied with the 
principle of the Bozeman button, as it prevented the operator 

Fig. 75. 



seeing the approximation, I had a fenestrated one constructed 
out of lead. (Fig. To.) Through the perforations in its 



REPORT OF CASES. 115 

centre-bar the wires were next passed, the button run down 
over the line of adjustment, and there maintained by passing 
the ends of each suture through a perforated shot, which, 
being slipped down in contact with the button, was there 
secured by compressing it between the blades of a strong pair 
of forceps. The wires were next collected together, brought 
out of the vagina, and wrapped with adhesive plaster to pre- 
vent excoriation ; and finally, the patient placed in bed, on 
her side, a catheter (Sims's) was introduced into the bladder, 
and the urine received on cloths placed beneath the end of 
the instrument. Half a grain of opium was directed to be 
given twice daily, and the diet to consist chiefly of arrow- 
root and cream. The catheter was to be closely watched that 
it should not become obstructed, to obviate which, it was to 
be removed once or twice a clay, and cleansed. a$o constitu- 
tional disturbance occurred, nor was there any local soreness 
experienced. On Wednesday afternoon, September 1st, being 
ten days after the operation, I proceeded to remove the button 
and sutures, when the union was found to be complete. As 
a precautionary measure, the catheter was directed to be worn 
eight days longer. On the twelfth day her bowels were 
opened, and again locked up for live or six days. Ten days 
after the removal of the ligatures, she was allowed to rise 
from her bed and walk about. 

Case II. — A. M., an Irish woman, about thirty years of age, 
during a severe labor, with a first child, ruptured her uterus, 
the child escaping into the abdomen. The fcetal head had 
not passed below the superior strait of the pelvis, the diame- 
ters of which were contracted. The case being under the care 
of the medical officers of the Nurses' Home, Dr. E. Wilson 
was immediately summoned to her aid by the attending phy- 
sician, Dr. Scholfield. The propriety of the abdominal section 
admitted of no question. The operation was accordingly 
performed by Dr. Wm. B. Page, the child removed through 
the parietes of the abdomen, and the life of the mother pre- 
served. Some time afterward it was discovered the rent in the 
uterine walls had extended through the cervix, and involved 



116 VESICOVAGINAL FISTULA. 

the vaginovesical septum, giving rise to a fistula. After the 
restoration of the woman's general health, she was placed in 
St. Joseph's Hospital, and at considerable intervals three un- 
successful attempts were made to close up the orifice, which 
was situated near the cervix uteri, and running in an oblique 
direction, about three-quarters of an inch in extent. Two of 
these operations were skilfully performed by the Bozeman 
method, employing as a retentive mechanism a lead plate or 
button. The patient was afterward placed in the Philadel- 
phia Hospital, under my charge, where, after some preliminary 
treatment to improve her general condition, she was operated 
on by the usual method, seven silver sutures being required 
to close it properly. On the eighth day the stitches were taken 
out, and the wound found to be only about one-half closed. 
On" carefully examining the parts, and reflecting over the for- 
mer failure, I thought I discovered the true source of diffi- 
culty, which subsequent events confirmed. The proximity 
of the fistula to the cervix uteri, the latter organ being some- 
what retroverted, prevented an accurate adjustment ; indeed 
the os was turned into the fistulous opening, and pressed to- 
ward the bladder. Profiting by this observation, at the 
second operation, undertaken nine weeks subsequently, I de- 
termined to turn the os into the opening permanently. With 
this end in view, the inferior semi-circumference of the fistula 
was well pared. Next the posterior half of the cervix uteri, 
after which eight silver sutures were introduced, and secured 
by the shot, the ends of the wire being cut off close to the 
latter. The os uteri was by this method turned into the 
bladder. Xothing worthy of note transpired during the sub- 
sequent progress of the case. On the eighth day following 
the operation, the parts were examined with a view to remove 
the ligatures, which were found in such excellent position, 
without any surrounding irritation, that, at the suggestion of 
Dr. E. Wilson, who rendered me valuable service in both ope- 
rations, I was induced to allow them to remain for two days 
longer. On the tenth day they were clipped out, and to our 
great satisfaction the fistula closed. Since that time this 
woman has menstruated regularly through the bladder ; en- 



REPORT OF CASES. 117 

joyed comfortable health ; been able to support herself as 
servant to a private family, and certainly rid of a most dis- 
tressing and disgusting malady. Two years after I operated 
on this same patient for strangulated umbilical hernia, from 
which she recovered without any unusual symptoms. It is 
not often we meet with an example of so many grave acci- 
dents, operations, and good recoveries, in one person, as are 
presented in the narrative of this poor, friendless Irish 
woman. 

Case III. — Catherine , a young woman aged 19 years, 

was seized with labor-pains, September, 1858, at the Philadel- 
phia Hospital. In consequence of the great size of the foetal 
head, it became completely impacted in the pelvic cavity. 
After ineffectual efforts to deliver with the forceps, the ope- 
ration of craniotomy was resorted to by Dr. R,. K. Smith, 
Chief Resident Physician,. and the child readily removed. In 
consequence, however, of the prolonged pressure sustained by 
the anterior wall of the vagina, a slough in a few days sepa- 
rated, opening a communication between that cavity and the 
bladder, through which the urine flowed. An examination, 
some weeks after, showed not only the existence of this fistula, 
but the canal of the urethra closed by inflammatory deposit. 
A trocar was at once carried through the obstructing material 
into the bladder, followed by a catheter, which was retained 
for eight days, only being removed for the purpose of cleansing. 
In this manner the urethra was restored. 

On the 16th of December following, the parts having be- 
come sufficiently callous, an operation was performed for her 
cure ; her bowels being well opened the day previous, after 
which one and a half grain of opium was administered. 

She was placed under the influence of a mixture of ether 
and chloroform, turned upon her abdomen, over a stool well 
protected, the limbs being supported by two assistants, and 
the parts exposed by a Sims's speculum. The fistula, which 
was transverse through the trigone vesicce, and exceeding an 
inch in its greatest diameter, could now be well seen. The 
edges were seized with the long rat-toothed forceps, and with 



118 VESICO-VAGINAL FISTULA. 

a long, straight, sharp-pointed bistoury, pared in their whole 
extent. Seven needles, slightly carved at their points, each 
armed with a silver thread, were carried successively, by 
means of the needle-holder figured in Fig. 60, through the 
edges of the wound, down to but not into the vesical mucous 
membrane. These sutures, being brought out of the vagina, 
were passed through the adjustor in succession, and drawn 
upon as the latter was passed down, thus approximating the 
edges very completely. Perforated shot were next run down 
over the wires, and clamped by means of the compressor. 
The sutures were now twisted together, and passed through 
a small tube of rubber to protect the parts, and the catheter 
carried into the bladder, to which was attached a flexible piece 
of gum elastic tubing, designed to convey the urine into a 
bottle properly placed between the limbs of the patient for 
its reception. The patient being placed in bed, an anodyne 
was administered ; the whole time consumed, including etheri- 
zation, did not exceed one hour. Everything progressed 
favorably until the third day, when, notwithstanding opium 
had been given to keep the bowels in a quiescent state, diar- 
rhoea, attended with considerable straining, came on, but which 
was at length controlled by enemata of laudanum. To make 
the case more embarrassing, a cough, which she had been 
troubled with for some time previous to the operation, 
harassed her so much, notwithstanding the free administra- 
tion of opium, as sometimes to drive the catheter out of the 
bladder. 

On December the 27th, ten days after the operation, the 
sutures were removed, and the wound found to have united, 
save at one single point, which was subsequently and perma- 
nently closed by a single stitch. The catheter was kept in the 
bladder a few days longer, in order not to endanger the cica- 
trix. This patient was watched with great care by Drs. 
Darby, Eichardson, and Taylor. 

Case IY. — Mary H , aged 25 years, unmarried, tem- 
perate, and a Philadelphian by birth, was received into the 
Philadelphia Hospital in September, 1858, pregnant. This 



REPORT OF CASES. 119 

was her second pregnane} 7 . In her first labor, she states, she 
was brought to bed on Monday morning, and delivered the 
following Thursday morning of a still-born child; the de- 
livery being brought about, as she says, by the physician in 
attendance using " forcing powders." 

On the 29th October, 1858, at 3J A.M., labor commenced. 
At 6 o'clock P.M., it was sufficiently advanced to establish 
the existence of a breech presentation in the first position. 
At 2 P.M., the foetus was expelled as far as the umbilicus; 
the limbs being much discolored from long-continued pres- 
sure in the pelvic cavity. The delivery of the head was de- 
layed by the chin leaving the breast, requiring finally the 
agency of the blunt hook to bring it down ; the labor being 
completed at 5 o'clock, making from its commencement thirty- 
seven hours and a half. Alarming hemorrhage followed, 
which was arrested by the removal of the placenta, frictions 
over the hypogastrium, and ice. The child weighed nine 
and a half pounds, and measured twenty-two inches in length. 
For twenty days the woman passed her urine naturally, and 
without pain or difficulty. On the twenty-first day it com- 
menced to flow through the vagina ; a slough having sepa- 
rated, and formed the fistula. Its situation was at the trigo- 
num vesicce, and about six lines in its greatest diameter. 

On the 14th of February, 1859, the parts having attained 
the requisite healthy conditions, the operation for cure was 
executed. An aperient was given the day previous. The 
woman was placed under an anaesthetic of ether and chloro- 
form (three parts of the former to one of the latter, by weight), 
turned over the padded stool on her abdomen, the hips being 
well elevated, and the fistula being exposed by introducing 
into the vagina the duck-bill speculum. The edges were next 
extensively denuded, and after the bleeding ceased, five silver 
sutures were inserted, and their ends brought out of the 
vagina, and the edges closed by the adjuster. Over each was 
passed a shot, and the stitch made secure by the compressor 
clamping it on the wires. The sutures were gathered together^ 
and passed through a piece of elastic tubing; the woman 
placed in bed, and the catheter at once inserted into the 



120 VESICOVAGINAL FISTULA. 

bladder, over the end of which was slipped the light gum- 
elastic tube, to convey the urine into a bottle properly placed 
in the bed. The bowels were controlled by opium, one-half 
grain, three times a day, for two days ; after which, the one- 
third of a grain three times a day. The diet consisted of 
nutritious broths, with some farinaceous articles. Nothing 
unusual occurred ; and on the eighth day the stitches were 
removed, and the cicatrization found to be complete. The 
bowels were gently opened on the ninth day, and the catheter 
continued five days longer. On the sixteenth day she was 
allowed to sit up, and on the twentieth day permitted to 
exercise in the ward. 

This case was reported in detail by Dr. Darby, in whose 
care the patient was. {Medical and Surgical Reporter, vol. 1, 
page 435.) 

Case V. — K. D., a Scotch girl, unmarried, 20 years of age, 
was admitted into the Philadelphia Hospital in April, 1859, 
pregnant. Her labor, which occurred in September, was 
difficult and prolonged, the head presenting, although the 
position is not known. She was finally delivered by the 
forceps, of a dead child, at the full term. One week after, 
the urine was observed trickling from the vagina, and, on 
examination some three weeks subsequent, a fistula was dis- 
covered, about seven lines long, and situated at the vesical 
triangle. Two months after her parturition she was trans- 
ferred to the Woman's Surgical Ward, and prepared for an 
operation by washing out the vagina every day with a solu- 
tion of tannic acid, to give some tone to the parts ; regu- 
lating the diet and improving her condition by tonics. After 
the lapse of another month she was considered well enough 
to justify an operation. This was performed in the presence 
of the house residents, in the manner already detailed in the 
previous cases. Seven silver threads were introduced (the 
patient being under the influence of ether and chloroform), 
and these stitches secured with the usual clamp of shot. 
Instead of bringing the wires out of the vagina after the 
adjustment, they were cut off close to the pellets of shot. 



REPORT OF CASES. 121 

Opium was administered in doses sufficient to keep the 
bowels closed, and the catheter kept in the bladder and care- 
fully watched that it should not become obstructed with 
mucus or blood. This girl proved to be a very self-willed 
and troublesome patient. 

On the ninth day after the operation the stitches were 
taken out, and the fistula, as we believed, closed. She was 
kept in bed with the catheter in the bladder for five days 
longer, after which she was allowed to sit up, the instrument 
being used four times daily, and worn at night for three 
days more, when it was laid aside and the patient allowed to 
walk about. She was retained in the house for two weeks 
longer, and then discharged well. 

About four months later this young woman returned, 
seeking admission, alleging that the fistula had reopened. 
She had evidently, from her own statements, been leading a very 
irregular life. On carefully inspecting the parts a small opening, 
admitting the end of a probe, was detected in the middle of 
the cicatrix. There could be no doubt this fistula had opened 
during her absence, as the bladder was perfectly retentive 
and the urine passed voluntarily in a full stream for the two' 
weeks previous to her leaving the hospital. Four operations 
were performed unsuccessfully to close this small hole, at in- 
tervals of eight weeks, and requiring but three stitches when 
freshened. I was satisfied there was something wrong, as 
there was nothing in the case which could explain this indis- 
position to heal. I suspected the woman was more anxious 
to have a home than to get rid of her disease, and doubtless, 
at night, in the absence of the nurse, withdrew the catheter, 
introducing it herself before her morning visit. Accordingly, 
on discovering my failure in the fourth operation, without 
waiting for some time to elapse, the parts were again denuded 
and two sutures inserted ; relays of nurses were kept night 
and day by her bed, and on the eighth day the parts were ex- 
amined and the sutures taken out. The opening was closed. 
The bowels had been confined for seventeen days, and after 
wearing the catheter four days longer she was allowed to 
dispense with its use. 



122 VESICO-VAGINAL FISTULA. 

My surmises in regard to the cause of failure were cor- 
roborated by her own confession. One year after, this poor 
unfortunate girl applied again for admission, not on account 
of the fistula, which remained well, but evidently dying 
from tuberculosis, induced by a life of dissipation. 

Case VI. — Ann H , a native of Ireland, aged 33 years, 

and a resident of Delaware County, Pennsylvania, was ad- 
mitted into the Philadelphia Hospital on the 24th of January, 
1860, with a vesico-vaginal fistula, situated three-quarters of 
an inch below the upper extremity of the vagina, four lines 
in length, and running oblique to the longitudinal axis of 
the canal. About ten months before her admission into the 
institution she had been delivered by instrumental means of 
a child, after a difficult labor of thirty-six hours' duration. 
I believe this was her second child. A few days succeeding 
this she discovered her urine dribbling away without being 
able to exercise any control over its escape. As the woman's 
health was by no means good, the first attention was directed 
to its improvement, which, under the employment of mineral 
tonics and a good diet, was, in a few weeks, in a good measure 
restored. The last of the succeeding month (February) the 
operation was performed while under the influence of ether 
and chloroform as an anaesthetic. Four silver sutures were 
introduced and secured by means of a wire-twister. The 
wires were next cut off very near to the wound, and the ends 
turned down in such a manner as not to irritate the posterior 
wall of the vagina. The catheter was worn uninterruptedly 
and the bowels locked up with opium. The case progressed 
without any unfavorable symptoms whatever, and on the 
eighth day the stitches were removed and the union found to 
be complete. The patient was retained in the hospital 
nineteen days longer, as a precautionary measure, during 
four of which she was obliged to wear the catheter. 

Case VII. — Matilda L , aged 24 years, was sent from 

Wilmington, Delaware, by Dr. Pepper Morris. She entered 
the hospital August, 1860. An examination proved the ex- 



REPORT OF CASES. 123 

istence of a vesico-vaginal fistula at the has fond, transverse 
in direction, and about six lines in length. It followed her 
first labor, which was sufficiently difficult to demand delivery 
of the child (dead-born) by the forceps. The presentation 
was a cephalic one, and she heard nothing said about any- 
thing being wrong. A few days after, she could not state 
how many, the urine began to flow from the vagina. The 
woman was pale, ansemic, and had but little appetite. She 
was placed on a regimen of tonics and nutritious food, in 
order to improve her health. Some progress was made, but 
by no means equal to our expectations, and after waiting five 
weeks I concluded to make an attempt for her cure. On 
paring the edges the bleeding became very profuse and con- 
tinued, notwithstanding the application of ice and a stream 
of cold water from the nozzle of a syringe. To arrest this, 
seven stitches were inserted and the edges drawn firmly 
together. Even these did not entirely control the hemorrhage, 
some considerable oozing continuing. The catheter was in- 
troduced into the bladder, and the patient placed in bed, with 
directions to administer the usual pills of opium. Difficulty 
was experienced in keeping the catheter clear, it becoming 
obstructed with clots of blood for three or four days. She 
suffered also throughout the whole treatment with flatulent 
colic and some diarrhoea ; the last was controlled by ene- 
mata of starch-water and laudanum, morning and evening. 
Her appetite failed and her stomach became irritable, for the 
relief of which alkalies were prescribed with benefit. At 
the expiration of nine days the sutures were examined, with- 
out being at all sanguine as to a favorable result. Several 
had ulcerated out, and no disposition was exhibited at any 
point to heal. They were all removed, and the patient, in a 
few days, ordered out to take exercise in the open air. 

Vegetable tonics, with an occasional mercurial, followed by 
the tincture of the chloride of iron, wrought a wonderful 
change in her condition, so that six weeks after we deemed 
her health sufficiently good to undertake a second operation. 
The edges of the fistula had changed. Instead of being 
spongy and soft, they had become firm. There was no more 



124 VESICO- VAGINAL FISTULA. 

than the ordinary bleeding after the application of the knife 
in vivifying the margins. Six metallic threads were intro- 
duced, secured each by the shot-clamp, and the usual treatment 
pursued. Not a single untoward symptom occurred, and 
after eight days the stitches were removed, and the union 
found complete. Dr. Recio, one of the resident physicians 
of the hospital, was unremitting in his care of this patient. 

Case YIII. — K. C, born in Ireland, recently from the 
vicinity of Bordentown, E"ew Jersey, aged 28 years, entered 
the hospital in the spring of I860, 1 with a vesico-vaginal 
fistula situated a short distance above the neck of the blad- 
der, oblique in position, and about five lines in extent. The 
entrance to the vagina was much constricted, rendering the 
exposure of the fistula difficult. The accident occurred about 
eighteen months before, in a first labor, in which a dead 
female child was delivered by instruments. She is not certain 
that the head presented. Difficulty was experienced in ad- 
justing the instruments, and she felt as though the vagina 
had been torn at the time. As the fistula was seated above 
the stricture, it became necessary to institute the preliminary 
treatment of dilatation, which was effected by gum-elastic 
bougies, after two weeks. This accomplished, the operation 
was performed in the presence of the medical residents, the 
patient being under the influence of the usual anaesthetic of 
ether and chloroform. After the edges were sufficiently de- 
nuded, six metallic (silver) threads were introduced, the parts 
brought in contact by passing each suture in detail through 
the adjustor, and securing the apposition by the shot-clamp. 
The rigid character of the vaginal walls, in consequence of 
the amount of cicatricial tissue, rendered all manipulations 
difficult. 

From this until the ninth day following, nothing of impor- 
tance occurred. The threads were on this day removed, and 
the fistula found about two-thirds closed. She was allowed 

J The record of this case being lost, I am unable to refer with certainty 
to the date of her admission, my own notes only containing the details of 
the operation. 



REPORT OF OASES. 125 

two months' respite, occasionally having a large-sized bougie 
introduced to counteract the persistent tendency to con- 
traction of the vaginal canal, after which a second opera- 
tion was executed, in which four stitches were inserted. 
A good deal of bleeding from the bladder followed for two 
days succeeding this, rendering it difficult to keep the ca- 
theter unobstructed. On the third day it ceased, and the 
case progressed very favorably during the remaining period 
of her treatment. The stitches were cut oat on the ninth day, 
the union having taken place throughout. This woman, after 
getting about, complained of some incontinence, and I was 
disposed to believe some minute orifice must still exist, al- 
though undiscovered. Since, however, the nurse informs me, 
this disappeared, and she left well. 

Case IX. — Mrs. G., an Irish woman, aged 40 years, who 
married late in life, fell in labor with a first child January, 
1863. She states her pains commenced on a Friday, and 
gradually increased in severity until the following Sunday, 
when she became so exhausted as to render the application of 
the forceps necessary to complete delivery. The child, a male, 
head presentation, was born dead. The bladder had not been 
catheterized. At no time after that had she a sensation like 
urine passing by the urethra. Her getting up was slow, and 
it was many weeks before she was able to walk, in conse- 
quence of a feeble state of the limbs, with diminished sensi- 
bility. In [November, 1863, she was kindly referred to me 
by Prof. F. G. Smith, of the University of Pennsylvania, to 
whose care she had been sent from the country. On examina- 
tion, a fistulous opening was found between the vagina and 
bladder, situated at the basfond, three-fourths of an inch in 
extent, and transverse in direction. 

On the 10th of November, I operated in my usual manner, 
assisted by Profs. F. G. Smith, Penrose, Drs. La Roche, and 
Boardman. Xine silver threads were inserted and secured by 
the shot-clamp. The usual course in regard to opium, ca- 
theter, and diet was observed. Xothing unusual occurred, 
worthy of note, during the treatment. On the ninth day the 



126 VESICO-VAGINAL FISTULA. 

stitches were removed, and the wound found united. The 
catheter was continued five days longer, the bowels being 
gently moved on the twelfth day after the operation. This 
patient I saw over two years after, when she stated she re- 
mained perfectly well, and was about four months advanced 
in her second pregnancy. 

Case X. — L. L., aged 35 years, from Pennsylvania, was ad- 
mitted to the Philadelphia Hospital in the month of April, 
1864, suffering from a transverse vesico-vaginal fistula, three- 
quarters of an inch in extent, and situated in the bas fond, 
with the complete destruction of the urethra. She was mar- 
ried at the age of 17 years, and 15 months after fell in labor 
with her first child at full term. She knows the child pre- 
sented by the vertex. After being in labor forty-eight hours 
the forceps was applied, and after one hour the child was ex- 
tracted dead, a male, and more than ordinarily large. Her 
urine, she states, was not drawn off', and she was never con- 
scious, after delivery, of passing her water the natural way. 
This fistula was, therefore, of over seventeen years' standing. 
The vagina had undoubtedly sustained much injury, as it was 
greatly narrowed in its whole extent. Her health was poor, 
and in no condition for an operation. She was placed on a 
tonic course of treatment, with some improvement, and on the 
9th of June, 1864, 1 concluded to make an attempt for her 
relief. The edges were pared, and fifteen wire threads inserted, 
securing each with the shot, which closed the vesico-vaginal 
rent satisfactorily. A catheter was placed in the bladder, and 
worn for nine clays, when the stitches were removed ; no 
attempt even at union seemed to have occurred. Increased 
attention was now given to her general health, aud on the 
28th of the following October, a second attempt was made, 
twelve stitches being inserted, and with an unsuccessful re- 
sult, union having taken place only to the extent of one-third 
of an inch. On the 3d of March, 1865, a third operation was 
executed, nine sutures being used, and the result was again 
unfavorable. On the 2d of June a fourth operation was per- 
formed, in which nine threads were employed, and this time 



REPORT OF CASES. 127 

with complete success. During the period she had been suf- 
fering from this fistula she had five miscarriages, all occurring 
at the fourth month. It is contemplated to attempt next the 
formation of a urethra for this patient. 

Case XL — Mrs. H., aged 28 years, residing in an adjoin- 
ing State, fell in labor with a first child. Her parturition 
was slow, vertex presentation, and becoming exhausted, the 
forceps was applied for her relief, and the process completed 
by the removal of a dead female foetus at full term. Four or 
five days following, her urine was discovered dribbling over 
the genitalia, and on inquiry, by her physician, little doubt 
was entertained that a fistulous opening existed between the 
bladder and vagina. On the 24th of May, 1865, eight weeks 
after recovery, I visited her, and on examination discovered 
the opening situated near the cervix vesicae, oblique in direc- 
tion, and about three-quarters of an inch in extent. She was 
placed under an anaesthetic of ether, and after freshening the 
margin of the opening, it was brought together by six sutures 
of silver wire, and clamped with shot, the usual detail of 
treatment being observed. In consequence of some pleuritic 
symptoms occurring about the eighth day, the stitches were 
not removed until the tenth day, when the wound was found 
thoroughly united. 

Case XII. — Mrs. M., of Philadelphia, aged 30 years, applied 
to be relieved of a vesico-vaginal fistula. A few months pre- 
vious she had been delivered of a dead child (her first), after 
being in labor forty-eight hours. It was a breech presenta- 
tion , and after the extrusion of the body, the head was re_ 
tained for several hours. At what time after, the opening 
occurred she could not determine, as she had no sensations 
decisive of the accident, but believes the urine dribbled ever 
after her labor. 

On the 24th of Xovember, 1864,1 operated, assisted by Drs. 
McLerny, Wilson, and Allen. The opening was situated 
about three-quarters of an inch above the cervix vesicae, trans- 
verse in direction, and about six lines in extent. It was freely 



128 VESICO-VAGINAL FISTULA. 

freshened, and closed with eight silver sutures. Nothing un- 
usual occurred during the subsequent course of the case, and 
on the ninth day the sutures were removed, the opening to all 
appearance closed. After getting up she was under the im- 
pression all was not quite right, as she was conscious of an 
unusual moisture at the outlet of the vagina, and her cloth- 
ing had a urinous odor; still she was able to pass her water 
in a fair stream. On examination I failed to detect any 
opening, although the bladder was not injected, the cicatrix 
looking so perfect. I was disposed to believe the urethra or 
neck of the bladder had not entirely recovered tone, and al- 
lowed some to escape, and advised the use of tonics, with the 
extract of nux vomica, and not to allow the urine to accumu- 
late. The difficulty was not relieved, and, on a second care- 
ful examination, an opening of almost capillary dimensions, 
was discovered at one angle of the cicatrix. The part was 
denuded, and two stitches inserted, which completed the cure, 
as she has since been perfectly well. 

Case XIII. — Airs. , set. 30, a small delicate lady from 

a distant land, in a first labor, greatly protracted, discovered, 
after five days, her urine running from her without control. 
She was informed that a fistula existed, and was for some 
time treated by cauterization. Becoming in the mean time 
pregnant, all remedial measures were suspended. Her confine- 
ment took place in Philadelphia, under the care of Dr. Stroud, 
seven weeks after which, I was invited by the doctor to visit 
her, and examine the case. The fistula was quite small, and 
situated in the vesical triangular space. On Sept. 12th, 1865, 
assisted by Drs. Stroud, Hunt, Rodman, and Townsend, I per- 
formed the usual operation, inserting, after the edges were 
properly denuded, four silver sutures, and securing them 
with shot. The subsequent treatment was conducted by Dr. 
Stroud. The only troublesome symptom arising in the pro- 
gress of her case was occasionally a violent spasmodic con- 
traction of the bladder, expelling the catheter, but which was 
overcome by enemata of a little thin starch-water with lauda- 
num. On the ninth day I removed the sutures, the opening 



REPORT OF CASES. 129 

being successfully closed. Very recentty I have heard from 
this patient, who continues to enjoy perfect health. 

Case XIV. — Mrs. G., aet. 29, residing in a neighboring vil- 
lage, went into labor with her first child. Her pains were 
severe and exhausting. The head of the child presented, and 
after thirty-six hours, the forceps were applied, and the child 
extracted, dead. Her urine had not been removed during 
labor, and she thinks that, four days after, it commenced 
escaping from the vagina. 

When I first visited her, she informed me a year and a half 
had elapsed since the accident, and that three operations had 
been attempted without success. On examination a double 
fistula was discovered, each running transversely through the 
vesical triangle, and separated from each other by about 
three-eighths of an inch. This condition was easily explained 
by referring to the previous operation — the middle of the 
wound uniting, and the extremities remaining open. Assisted 
by Drs. Morton, Sutton, Agnew, and Weightman,I operated 
a few days after, by paring the edges of each, and closing one 
with five and the other with four sutures. Everything pro- 
gressed well until the third clay, when she was seized with 
pain in the abdomen, with free bleeding from the vagina, 
which at first I was disposed to believe was a copious men- 
struation. Her bowels also became disturbed, and her appe- 
tite failed. Opium and warm fomentations relieved her pain 
and diarrhoea, but the bleeding continued for seven days. On 
the ninth day, the threads were removed, one fistula being 
found closed, and the other open. After this the woman be- 
came pale and dyspeptic, and in no condition to justify an 
operation. Under a properly regulated diet and tonics, she 
improved rapidly in general health, and in the meantime be- 
came again pregnant. 

Two months after her confinement, on the 4th of Novem- 
ber, 1865, assisted by Drs. Patterson, Hall, and Townsend, I 
operated, closing the opening with nine metallic threads. 
Kot an unpleasant symptom occurred, and the sutures were 
removed on the ninth day following, the wound proving to 



130 VESICOVAGINAL FISTULA. 

be closed soundly in its entire extent. An interesting fact 
connected with this case was the disposition, if she allowed 
her bladder to become too much distended, to some incon- 
tinence. To correct this an elastic-ring pessary was intro- 
duced, which, by its pressure on the neck of the organ, 
effectually relieved the difficulty. 

Case XV. — S. G-., aged 25 years, a native of Ireland, was 
admitted into the Pennsylvania Hospital October the 10th, 
1865, suffering from a vesico-vaginal fistula since the April 
previous. It occurred as a consequence of a tedious labor 
with her second child, forty-eight hours having elapsed before 
it was delivered. Her physician stated to her it was a cross- 
birth. £u> instruments were used, but the leg of the child 
was broken in two places. Of course the foetus was dead. 
The time she passed her urine first through the vagina she 
could not determine, but thinks before the second day after 
her confinement. At the expiration of two weeks she got 
up, but found herself so weak on her limbs as to be unable 
to walk. Her first labor was not difficult. After her re- 
covery two operations were performed for the closure of the 
fistula, by her physicians ; both unsuccessful. On examina- 
tion, after her admission, the fistula was found to extend lon- 
gitudinally from the neck of the bladder to the os uteri, and 
inclining to the left of the cervix passed along its entire 
length. 

On the 24th of October, assisted by Drs. Hunt, Morton, 
Hewson, and the hospital residents, I executed the operation 
described in the previous cases. As the neck of the uterus 
formed one side of the fistula above, the os looking into the 
bladder, it was necessary to freshen it, and secure it to the 
opposite side. The opening was closed longitudinally with 
thirteen sutures. J^ot an unfavorable symptom followed the 
operation, and on the ninth day these stitches were taken 
out, and except at a single point, where the vaginal wall 
blends with the cervix uteri, a solid union secured. To close 
this a second operation was performed, eight weeks after, 
requiring three stitches, and resulting in complete closure. 



anomalous symptoms. 131 

Anomalous Symptoms. — Death. — Pyemic Peritonitis. 

REPORTED BY DR. WILLIAM PEPPER, RESIDENT PHYSICIAN. 

Case XVI. — Cornelia Augusta Handy, set. 24, colored, was 
admitted to Pennsylvania Hospital April 14th, 1866, suffer- 
ing with a vesico-vaginal fistula of very great size, resulting 
from prolonged second stage in her first labor, six months 
ago. She has been for years in delicate health, though evinc- 
ing no positive sign of organic disease. Dr. Agnew operated 
upon her, Thursday, April 19th, 1866, the edges being pared 
and brought together, antero-posteriorly, by thirteen silver 
sutures, clamped with shot ; the two upper stitches including 
the involved anterior lip of the os uteri. A full opiate was 
administered, and a self-retaining catheter introduced. The 
urine came readily through catheter, and the woman did 
well until the afternoon of Saturday, April 21, 1866, when 
she had a very slight chilly sensation, followed by scarcely 
any fever or sweat. The following morning I found her with 
a dry hot skin, restless, lying on her back with legs drawn 
up, complaining much of abdominal tenderness. The entire 
abdomen was sensitive to pressure, rather more markedly so 
in the hypogastric region than elsewhere. There had been 
very little hemorrhage, and the catheter remained quite clear. 
She was at the time under mild opiate influence — having 
taken gr. j twice daily. Bowels constipated. Opium and 
emollient applications to abdomen were ordered, but during 
the day she had four or five thin serous stools, and vomited 
a number of times, the abdominal symptoms remaining un- 
abated. No recurrence of chill. 

April 23d. Much the same. Diarrhoea and vomiting per- 
sisting. Complains of abdominal tenderness. Tongue furred 
in centre, merely dryish. Pulse rapid and small. Catheter 
runs freely, but little blood passing. No chill or chilly sen- 
sation. Opii gr. J, calomel gr. ss, q. t. h. Hop poultice to 
abdomen. Light diet. 

April 24th. Expresses herself as feeling better. Less abdo- 
minal tenderness. Belly not distended. No vomiting. Less 



132 VESICOVAGINAL FISTULA. 

diarrhoea. There is, however, extreme huskiness of voice, 
and mental dejection. 

April 25th, 26th, 27th, 28th. Remained in much the 
same condition, excepting that great jaundice came on, the 
conjunctivae being deeply yellow, and the jaundice-tinge 
showing through the dark skin. The vomiting has not re- 
curred; but, despite the free use of opium, she had several 
thin stools daily. The calomel and opium were suspended 
after sixty hours, as the abdominal tenderness disappeared 
almost entirely ; the pulse became less frequent, and the skin 
less parched and dry; and Huxham's tincture of bark, with 
nitro-muriatic acid and a small amount of stimulus, were 
ordered. There was nothing like a chill or intermission in 
the febrile movement. The voice remained very husky and 
feeble, and she evinced great hebetude. 

April 29th. Expressed herself as feeling more comfortable. 
Had some appetite. Pulse not more than 110. Jaundice 
somewhat decreased, perhaps. Bowels more quiet. Tongue 
dryish and coated. Abdomen not sensitive, rather retracted. 
~No cough. Heart sounds healthy. ~No delirium or brain 
symptoms. Yoice extremely feeble, but is a little more 
animated. 

April 30th. Stitches removed by Dr. Agnew. The an- 
terior half of fistula found to have healed, this being the 
twelfth day. The vagina was coated with yellowish layers 
of lymph, mixed apparently with urinary salts. Condition 
very much the same. 

May 1st. Much the same. Pulse small, but not so frequent. 
Skin not harsh. Tongue dryish. Jaundice marked. Con- 
siderable hebetude, but perfectly rational, and expresses her- 
self as feeling more comfortable and stronger. Her appear- 
ance, however, belies her, as she was evidently emaciating 
rapidly. Her voice was almost extinct. She seemed to be 
more easy when lying on her side, and yet was almost unable 
to turn over. Made no complaint of pain. Had no diarrhoea 
or vomiting. Took nourishment quite well, and passed the 
day much as usual, but about 10 P. M., after having spoken 



ANOMALOUS SYMPTOMS. 133 

to the night nurse five minutes previously, she was found 
dead, lying quietly in the same position — on right side. 

Post-mortem fifteen hours after death. Quite marked rigor 
mortis. Body emaciated. Spine not examined. 

Brain presented no abnormal condition^ save that it, like 
all other parts of the body, was deeply stained of a yellowish 
hue. The blood in the cerebral veins was clotted, as it was 
in most of the vessels of the body. 

Thorax. — Lungs anaamic, congested postero-inferiorly, but 
contained no pysemic deposits. Bronchial glands not en- 
larged. Heart contained no fluid blood, and a very small, 
quite firm coagulum in right ventricle, extending into pul- 
monary artery, but by no means filling its calibre. Healthy 
in structure, though these organs, as all the others, were 
stained yellow. 

Abdomen. — On opening the abdominal walls, there was a 
gush of thick yellowish, ochre-colored fluid, identical in 
thickness, color, and smell, with the fluid so often seen in 
pyeemic pleurisies, and upon examining the cavity of the 
abdomen, it contained at least Oij of this fluid. All of the 
viscera were coated more or less with yellowish cheesy-look- 
ing lymph, although the spleen, greater omentum, and ileum 
were so to a most marked degree. Upon stripping off this 
lymph, the subjacent peritoneum seemed almost entirely 
healthy, not having even an excoriated appearance. In no 
place had any adhesion formed between two portions of this 
deposit. 

The liver was of normal size and consistence, but deeply 
stained with the same yellowish tinge as were the other 
organs. 

Gall-bladder pale and almost empty. 

Spleen slightly enlarged and rather soft. 

Pancreas healthy. Kidneys apparently healthy. 

There was an increase of these appearances over the blad- 
der and rectum, and upon opening the bladder, it was found 
merely much discolored by chronic congestion. It was some- 
what thickened, but no evidence of any recent inflammation. 

The uterus was of fair size, firm, and on section presented 



134 VESICO-VAGINAL FISTULA. 

a normal appearance. The mucous membrane of its cavity 
was dark and somewhat thickened. ~No evidence of inflam- 
mation of uterine veins. Fallopian tubes healthy apparently ; 
calibres free. 

The fistula was found, as stated, reduced in size. Edges 
presenting a pale granulating surface encrusted with phos- 
phates. The neck of uterus, we have seen, was turned into 
the bladder, and the highest stitches almost passed through 
tissue of the os, but no evidence existed of any uterine in- 
flammation, or of the peritonitis having started from this 
point. 

Stomach and intestines presented nothing to account for 
gastro-intestinal symptoms, excepting some softening and 
thinning: of the mucous membrane. 

Urine could not, of course, be obtained. 

The fluid in abdomen contained granular corpuscles, with 
single or double nuclei (some with none apparent), large nucle- 
ated cells, a little hsematin. After addition of acetic acid, a 
few corpuscles showed trefoil nuclei. Most of the corpuscles, 
however, had but one or two. Some coagulation of mucus. 
The whole being evidently cacoplastic lymphy fluid. 

The blood, bistre tinted, pale and thin, clotting imperfectly 
though quite rapidly, forming large dark clot, full of white 
corpuscles. "No attempt at formation of rouleaux. Red cor- 
puscles crenated. Quite numerous flakes of hsematin. 

There was no enlargement of inguinal, pelvic, or lumbar 
glands. 

REPORTED BY DR. ANDREWS, RESIDENT PHYSICIAN. 

Case XYII. — M. S., set. 38 years, a native of Ireland, was 
admitted into the Pennsylvania Hospital, February 13th, 
1866, suffering with vesico-vaginal fistula. She was a woman 
of good habits, but living in a miserable house, in the vicinity 
of one of our suburban towns. The accident happened with 
her fifth child ; was delivered with instruments, after being in 
labor two days. Presentation, head. In her former labors 
she had experienced no trouble. The fistula, on examination, 
proved to be longitudinal, and quite two inches and a half in 



ANOMALOUS SYMPTOMS. 135 

length. The tissues appeared healthy. After a few days of 
preparation, consisting in regulating the diet and opening the 
howels, the operation for her cure was performed by Dr. 
Agnew, in presence of Drs. Hunt, Morton, and the resident 
physicians of the hospital. The patient being under the in- 
fluence of ether, the edges were extensively pared, and four- 
teen silver stitches inserted, which were secured by the shot- 
clamp; the approximation being effected longitudinally. She 
was now placed in bed, a catheter placed in the bladder, and 
one grain of opium ordered morning and evening. For four 
days everything went on well ; all the urine passing by the 
catheter, appetite good, pulse normal, and abdomen soft. On 
the 5th she was taken with a severe chill, followed by head- 
ache, vomiting, and mental aberration. As she had suffered 
from chills before entering the hospital, it was hoped this 
might be nothing more than a return of the intermittent 
attack, and accordingly quinine was prescribed in antipe- 
riodic doses. 

6th. Vomiting continued ; bowels loose; delirium increased ; 
eyes inflamed ; tongue dry and crisped. Lime-water and 
milk administered ; also camphor-water, with liq. morph. sul- 
phatis. 

7th. Some abatement of vomiting ; stomach retains a little 
liquid nourishment ; bowels very loose, with dyspnoea and a 
sensation of choking ; also some tympany ; pulse 100. Beef 
essence, and an enema of tinctures opii gtt. 1, in a little starch 
water. 

8th. Eruption made its appearance over the abdomen, re- 
sembling that of typhoid fever; belly tympanitic; tongue 
dry and brown ; dyspnoea less ; pulse becoming more frequent ; 
twelve of the stitches were removed by Dr. Agnew, with the 
assistance of Dr. Hunt, the union appeared complete, save a 
small point at the upper extremity of the wound. The re- 
moval was dictated by the feeling, that, possibly, they might 
have kindled up inflammation, which had extended to the 
serous lining of the pelvis and abdomen. Ten drops of oil of 
turpentine, in mucilage, directed every two hours ; beef-es- 
sence ; milk-punch. 



136 VESICO-VAGINAL FISTULA. 

9th. Patient exceedingly exhausted ; pulse very frequent ; 
muttering delirium ; diarrhoea ; enema of laudanum ; con- 
tinue stimulants and nourishment. 

10th. Died. 

Post-mortem, six hours after death. Adhesions between the 
margins of the fistula had given way, and were coated with 
a dirty lymph ; no inflammation of bladder or uterus. The 
viscera of the abdomen were much congested, though not in- 
flamed. Peyer's patches healthy ; no signs of ulceration ; no 
peritonitis ; no metastatic abscesses. The lungs somewhat 
congested (hypostatic) ; the pulmonary pleura covered with 
soft lymph. During life, a blowing sound emitted with the 
first sound of the heart was noticed, but no lesion of the 
organ appeared on examination. The blood was remarkably 
fluid. In all probability, had this patient been operated on 
outside of the hospital, the termination would have been 
otherwise. A number of cases of pyaemia having occurred in 
the wards, the atmospheric conditions were beyond all doubt 
unsafe. The same may be asserted of Case XYI. 

Case XVIII. — Rose , an Irish woman, aged about 

33 years, was admitted into the Pennsylvania Hospital in 
June, 1866, for vesico-vaginal fistula. On examination, a 
stricture of the vagina was found about the middle of the 
canal, the opening not exceeding a quarter of an inch in ex- 
tent. The tissue around was dense, almost cartilaginous in 
consistence, and the vagina greatly diminished above. It was, 
of course, impossible to see just where the communication 
with the bladder existed, but of the fact no doubt existed, as 
the urine all passed through the vagina. The accident oc- 
curred in a first labor, which had been tedious, lasting two 
days. Thinks no instruments were used. Did not understand 
anything was wrong. It was of eight years' standing, and 
had once been operated on by a surgeon without success. Her 
health was tolerably good, though she was exceedingly ner- 
vous. I concluded to vivify the edges of the vaginal stricture, 
and unite them with the metallic threads, thus converting the 
narrow upper part of the vagina and the bladder into a com- 



ANOMALOUS SYMPTOMS. 137 

mon cavity. This course was resolved upon, as the thickening 
and extensive rigidity of the vaginal walls would have made 
the process of dilatation very slow and unsatisfactory. This 
was accordingly done, and four sutures inserted, secured in 
the usual way. The bladder was kept drained with the self- 
retaining catheter, and. everything passed satisfactorily until 
the fourth day, when she complained of great abdominal dis- 
tension, with severe paroxysms of pain. All of this was due 
to accumulation of flatus, and nothing seemed to control it. 
Her appetite failed, and she was harassed with nausea. On 
the ninth day the stitches were taken out, but no union had 
occurred. She left the hospital with the understanding she 
should return, with a view of giving her some preliminary 
general treatment before another operation should be under- 
taken. 

I have now performed this operation about sixty times, 
with three deaths, all doubtless due to a hospital atmosphere, 
and, as far as I know, with not more than four or five failures. 



10 



I O E X 



4 DJUSTMENT of lacerations, 35 
J\ of fistulas, 88, 90, 94, 97, 106 
Adjuster, 94 

Anesthetics, 100 

Anatomy of perineum, 10-11 

Approximation of fistula, 105 

direction of, 105 
Assistants, 28, 100 



T)ERNARD and Huette's operation, 

Bladder, irritable, 108 

treatment of, 109 
Bleeding, how to stop, 35, 100, 105 
Brown, I. Baker, on period of lace- 
ration, 11-12 

operation for laceration, 25 
Burns's operation, 22 
Button, lead, author's, 114 

Battel's, 98 

Bozeman's, 92 



pATHETER, 100 
\J cleansing of, 108 

directions for use, 107, 138 

for carrying a needle, 75 

self-retaining, 90 
Causes of failure to cure, 111 

of lacerations, 12 

of vesico-vaginal fistulas, 61-64 
Clamps, 87 
Classification of lacerations, 13 

of vesico-vaginal fistula, 64 
Complication in vesico-vaginal fistu- 
la, 69, 112 
Contra-indications to operate, 27, 68 
Crotchets for button, 94 

Simpson's, 96 



DEFORMITY from laceration, 17 
Degrees of ruptured perineum, 
13 
Diagnosis of vesico-vaginal fistula, 66 
Diet after operations, 38, 109 
Direction of fistulas, 65 



EXAMPLES of cases of laceration 
of perineum, 39-52 
of cases of vesico-vaginal fistula, 
113-137 



FECAL accumulations, 39 
Fistula, vesico-vaginal, con- 
founded with relaxed muscular 
walls, 67 
vesico-vaginal, failure to cure, 111 
signs of, 66-67 
Fistulas with carcinoma, 69 
Flatus, accumulations of, 38, 109 
Forceps, Agnew's, 29, 101 
Fork, adjusting, 88 
Fork, Hilliard's, 104 



G 



UM tubing for catheters, 107 



HEMORRHAGE, its arrest, 105 
History of laceration, 19-25 
of vesico-vaginal fistula, 57-61 



INSTRUMENTS for lacerations, 
1 29, 30 

for vesico-vaginal fistula, 100, 101 



T ACERATED perineum, 9 
Li cases treated of, 39-51 

causes of, 12, 13 

deformity from, 14 

degrees of, 13 

history of, 19-25 

literature of, 52-56 

period of, 11 

prevention of, 14-19 

results of, 13 



M 



EADOWS, Dr., operation, 99 
Metallic shield of Meigs, 20 
Mirror, 21 



140 



INDEX. 



VEEDLE for deep sutures, 29, 30 

IN Colombat, 78 

used by Sims, 85 
for silver wire, 102 
-holder, Bozeman's, 93 
Simpson's, 96 







PERATIONS for lacerations, 28 
Agnew's operation, 34 
Aitkeu's, 20 

Bernard and Huette's, 23 
Blundell's, 21 
Boyer's, 20 

Brown's, I. Baker, 21, 25, 31 
Burns' s, 22 
Busch's, 20 
Chelius's, 22 
Churchill's, 21 
Clay's, 24 
Cockle's, 21 
Davidson's, 22 
Davis's, 21 
De la Motte's, 20, 21 
Deleurye's, 20 
Dietfenbach's. 21, 22 
D'Outrepont's, 20 
Duparcque's, M., 20 
Dupuytren's, 21 
Gross's, 25 
Guerin's, 23 
Holmes's, 24 
Homer's, 25 
James's, 22 
Jobert's, M., 24 
Kilian's, 22 
Langenbeck's, 23 
Menzel's, 22 
Mettauer's, 25 
Miller's, 24 
Nevermann's, 22 
Pare's, Ambrose, 19 
Roux's, 23 
Sedillot's, 23 
Skey's, 24 
Smith's, H. H., 25 
South' s, 22 
Yerhaege's, 23 
Vidal's, 24 
Wutzer's, 22, 23 
assistants for, 28 
contra-indications for, 27 
diet after, 38 
history of, 19, 25 
instruments for, 29, 30 
position for, 28 
preparation of bed for, 28 
preparation of patient for, 27 
preparatory treatment for, 34 



Operations — continued. 

primary and secondary, 25, 26, 
37 

time for, 25 

treatment after, 37 

for vesi co- vaginal fistulse — 

of Agnew, 99 

of Beaumont, 79 

of Betancourt, 73 

of Blasius, 77 

of Bozeman, 92 

of Boyer — Desault, 71 

of Collis, 98 

of Colombat, 73, 78 

of Deybers, 78 

of Dieffenbach, 79 

of Ehrman, 76 

of Fabricius Hildanus, 70 

of Gosset, 77 

of Hayward, 80 

of Jobert, 74 

of Kilian, 77 

of Lallemand, 73 

of Laugier, 73 

of Lewzisky, 77 

of Luke, 76 

of Malagodi. 76 

of Marshall, 74 

of McGuire, 95 

of Meadows, 99 

of Mettauer, 81 

of Nagele, 75 

of Pancoast, 81 

of Roonhuysen, 75 

of Roux, 79 

of Shraeger, 76 

of Simpson, 95 

of Sims, 81 

of Yolter, 75 

of Wutzer, 79 
Opium, its use, 108 



PARING edges of lacerations, 34 
fistula, 22-92 
Perineum, form of,- 12 

its anatomy, 10, 11 

its measurements, 9 

its support, 15, 19 

period of lacerations of, 11 
Prevention of lacerations — 

Blundell on, 18 

Burns, 16 

Bush, 16, 18 

Carus, 17 

Cazeaux, 17 

Denman, 17 

Hamilton, 16 

Heine, 16 



INDEX. 



141 



Prevention of lacerations — continued 

Hodge on, 17 

Hohl, 16 

Meigs, 17 

Mende, 17 

Mesnard, 17 

Micliaeles, 17 

Ritgen, 17 

Siebold, V., 17 

Velpean, 17 
Position of patient in lacerations, 28 

in vesicovaginal fistula, 103 
Preparation for operations, 100 



Q 



UILLED suture, 25 



RECEPTACLES for urine, 70 
Results of lacerations of perine- 
um, 13 



OHOT, 89, 102 

U compressor, 89, 100 

in position, 107 

perforator, 100 

removal of, 110 

removed, 110 
Skin, incisions of, in lacerations, 33 
Speculum, 83 

Bozeman's, 83 

in position, 83, 103 

Sims's, 83 

Wutzer's, 79 
Sphincter, extension of, 31 

incisions of, in lacerations, 34 
Sponge tents, 70 
Supporting perineum, views of — 

Hodge, 17 

Meigs, 17 

Penrose, 18 

Sacombe. 15 

Schaffler, 15 

Siebold, 15, 17 

Simpson, 18 

Stark, 15 

Stein, 15 



Supporting perineum — continued.. 

views of Stein, Sr., 15 
of Wilson, 18 
Suture, 21-75 

advocates for, 21 

gilded, 77 

glover, 76, 78 

grooved, 77 

introduction of, 35, 105 

iron, 35 

lead, 81 

quilled, 31, 87 

removal of, 38, 109 

securing, 36, 94, 97, 98, 107 

silver, 82 

twisted, 79 



TIME to operate, 100 
Treatment of vesico-vaginal fis- 
tula, 79 
by catheter, 71 

and tampon, 71 
cauterization, 72 
galvanism, 74 
palliative, 70 
radical, 71 
suture, 75 
transplantation, 74 
uniting apparatus, 73 
Tympanitis, 109 



UNITING apparatus of Dr. Betan- 
court, 74 
of McGuire, 95 
of Laguier, 73 
Urethra, irritable, 108 
Urinary stillicidium, 69 

incontinence, 113 
Uterus in bladder, 116 



y AGIN A, injections of, 70 
V Vesico-vaginal fistula, 57 

\Y IRE splint of Simpson, 97 
IT twister, 97 



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